Presented in honor of 
 
 William R. Laughlin, D. 0. 
 
 by 
 Mrs. William R. Laughlin 
 
 COLLEGE OF OSTEOPATHIC PHYSICIANS 
 AND SURGEONS LOS ANGELES, CALIFORNIA
 
 WILLIAM ROSS LAUGHLIN 
 M.S. - D.O. 
 
 Los ANGELES, CALIFORNIA
 
 Diseases of WomerTl 
 
 A MANUAL OF GYNECOLOGY DESIGNED FOR THE 
 
 USE OF OSTEOPATHIC STUDENTS AND 
 
 PRACTITIONERS 
 
 BY 
 
 LARK, D. O.. 
 
 Professor of Gynecology and Obstetrics in the American 
 
 School of Osteopathy; Member Operating Staff 
 
 A. T. Still Infirmary. 
 
 SECOND EDITION. 
 
 Thoroughly Revised, with 111 Illustrations. 
 
 MONOTYPElt BY 
 
 JOURNAL PIUNTING COMPANY, 
 
 KIRK8VILLE, MO. 
 
 1904
 
 CL 
 
 Copyrighted by 
 
 M. E. Clark, 
 
 1904.
 
 PREFACE TO SECOND EDITION. 
 
 The very gratifying reception accorded to the first edition 
 of this work has prompted me to make the second edition still 
 more acceptable to the profession. 
 
 I have rewritten a great deal of the subject matter and the 
 other subjects have been much enlarged. In addition many new 
 sections and interpolations have been added. 
 
 Much attention has been paid to the causes and treatment 
 of female diseases from the bony lesion standpoint. Surgical 
 gynecology has been purposely left out. 
 
 The most of the illustrations are original, while the proper 
 credit is given for those copied. 
 
 M. E. CLARK. D. O. 
 
 .Kirksville, Mo., September, K04.
 
 DISEASES OF WOMEN. 
 
 CONTENTS. 
 
 INTRODUCTION. 
 DEVELOPMENT. 
 
 ANATOMY: External Genitalia; Vagina; Uterus; Ovaries; 
 Tubes; Urethra; Bladder; Pelvic Peritoneum; Pelvic Floor; 
 Pelvic Connective Tissue; Bony Pelvis. 
 
 GENERAL CAUSES OF DISEASE. 
 METHODS OF EXAMINATION. 
 DISEASES OF THE VULVA. 
 
 AFFECTIONS OF THE UTERUS : Relations ; Normal Position; 
 Support^; Varieties of Displacement; Prolapsus Uteri; Re- 
 placement; Anteversion; Anteflexion; Retroversion ; Retro- 
 flexion; Inversion. 
 
 TUMORS OF THE UTERUS. 
 LACERATION OF THE CERVIX. 
 
 INFLAMMATION OF THE UTERUS : Endometritis ; Metritis; 
 Perimetritis. 
 
 PHYSIOLOGICAL PERIODS: Infancy ; Puberty ; Maturity ; 
 Menopause; Senility. 
 
 GENERAL DISORDERS OF MENSTRUATION: Amen orrhea; 
 Scanty Menstruation; Dysmenorrhea ; Menorrhagia; Vicar- 
 ious Menstruation.
 
 CONTENTS. 5 
 
 DISEASES OF FALLOPIAN TUBES. 
 OVARIAN DISEASES. 
 REFLEX DISORDERS. 
 
 MISCELLANEOUS AFFECTIONS : Sterility ; Masturbation ; Abor- 
 tion; Ectopic Gestation; Mammary Diseases; Hernia; 
 Hemorrhoids; Sciatica; Chlorosis; Milk Leg; Skin Eruption; 
 Leucorrhea in Children: Diseases of Rectum; Rheumatism.
 
 DISEASES OF WOMEN. 
 
 INTRODUCTION. 
 
 GYNECOLOGY is the science which treats of the diseases 
 PECULIAR TO WOMEN. Since woman possesses organs which man 
 has not, and as the role she plays, both physiological and social, 
 differs from that played by man, we would expect to find her 
 afflicted with a NUMBER OF DISEASES peculiar to herself, which 
 depend on her make-up, function and habits. As far back as 
 history carries us we find mentioned certain diseases peculiar to 
 women. Instruments have been found, such as sounds and 
 various forms of specula, which indicate that uterine diseases 
 were recognized and that attempts were made to correct them 
 even at that early date. 
 
 Prior to the time of Sims, the practice of gynecology con- 
 sisted, for the most part, in replacing the malposed uterus, ad- 
 justing pessaries, and the application of various medicinal agents 
 to the cervix and uterine canal. Within the last decade gyne- 
 cology has developed into a science distinctly surgical, when 
 viewed from the standpoint of an abdominal surgeon or the so- 
 called specialist. ALL CHRONIC CONDITIONS ARE looked upon as 
 surgical, and such operations as curettage, ovariotomy or some 
 form of laparotomy is performed for the most trivial ailments, 
 while in some, the operation is performed as an experiment or 
 for the purpose of diagnosis. SHORTENING of the uterine liga- 
 ments and operations on the vagina and pelvic floor, such as 
 colporrhaphy and perineorraphy, are the operations that are 
 most frequently performed. 
 
 During this period Dr. A. T. Still, noting the prevalence of
 
 INTRODUCTION. 7 
 
 and tendency to, surgical operations, reasoned that "A WOMAN 
 
 WAS NOT MADE TO BE MAIMED BY USELESS SURGICAL EXPERI- 
 MENTS." He began to study the human body, its mehcanism, 
 parts, and functions of all these parts, but particularly the pel- 
 vic viscera. As a result of this study, a new system of thera- 
 peutics in general was evolved, which he called osteopathy; while 
 a new system of gynecology in particular, was given to the world, 
 marking the beginning of an epoch, for the relief and cure of 
 female diseases, greater than any previous one marked by any 
 new mode of treatment. 
 
 The basic principle of osteopathy in general, and osteopathic 
 gynecology in particular is, that A PERFECTLY ADJUSTED BODY 
 
 IS NECESSARY TO HEALTH; AND THAT A PERFECT ADJUSTMENT OF 
 THE PARTS CONCERNED IN THE FORMATION OF THE FEMALE SEX- 
 UAL APPARATUSES NECESSARY TO THEIR PERFECT FUNCTIONING; 
 
 this perfect adjustment existing, HEALTH PREVAILS. 
 
 NERVE FORCE must be DISTRIBUTED to EVERY PART OF THE 
 HUMAN BODY. The BLOOD must be kept in MOTION ALL THE 
 TIME, not lagging for an instant, or its vitality lowers and a pre- 
 disposition to disease follows. 
 
 Dr. Still reasoned that a DERANGEMENT OF THE FRAME- 
 WORK of the body affected the structure and function of the vis- 
 cera directly or indirectly in relation with the deranged part; 
 these effects interfering with normal nerve supply to, and cir- 
 culation through, these structures and viscera. These derange- 
 ments of the framework consist of partial or complete disloca- 
 tion of vertebrae, especially the lumbar, and of the sacrum, 
 coccyx, innominata, ribs and hip bones. Visceral lesions, such 
 as displacements of the intestines, and the uterus with its at- 
 tachments and appendages, are recognized as important causes 
 of interference with distribution of blood and nerve force.
 
 8 DISEASES OF WOMEN. 
 
 These theories have been put into practice by osteopathic 
 physicians and proven beyond successful contradiction, thus 
 marking a new era in gynecological therapeutics. 
 
 Formerly, strange theories were advanced as to the causes 
 of female diseases. Some found the explanation of all uterine 
 diseases in congestion, others in displacements; one declared 
 "leucorrhea to be the great evil;" another, ulcerations and gran- 
 ulations. Most of the modern teachers are inclined to trace them 
 to inflammation. Necessarily as a result of these varied ideas, 
 exclusive therapeutists developed. Congestion was treated by 
 blood letting, displacements by various mechanical devices, 
 while others directed all their attention to the curing of the 
 leucorrhea. 
 
 On account of IGNORANCE OF THE FUNCTION OF THE FEMALE 
 GENITAL ORGANS and their relation to disease, I think they have been 
 MALTREATED more than any other part of the body. One extreme 
 has followed another; experiment after experiment has been per- 
 formed, and the latest fad or experiment is operation. If the 
 patient has painful menstruation or a chronic abdominal pain 
 an operation is at once advised. I am glad to say that the os- 
 teopath does not have to resort to such for relief in the vast ma- 
 jority of cases, but relieves the sufferer without unsexing her by 
 an operation. Thus from an uncertain experimental condi- 
 tion, OSTEOPATHY steps forth a certain and perfect science. I 
 sincerely believe that the science of osteopathy is the only ration- 
 al and natural way of treating ailments peculiar to women. 
 
 THE OSTEOPATH views these diseases from an entirely 
 different and new standpoint; at least the method of correct- 
 ing them is new. While some of the causes usually mentioned 
 are recognized, other causes MORE POTENT, which belong to the 
 REALM OF OSTEOPATHY, are regarded as the most important,
 
 INTRODUCTION. 9 
 
 and by removing these, permanent cures result. The osteopath- 
 ic idea depends on PROPER ADJUSTMENT of both the internal 
 organs of generation and the bony framework in which they are 
 located. Any displacement of either one tends to interfere with 
 the normal distribution of blood and nerve force, both of 
 which are requisite to perfect health. Pure blood is moving 
 blood, and it cannot be pure and be stagnant at the same t i me- 
 lt' the blood is circulating properly, HEALTH MUST ENSUE; that 
 is, our object in treating these diseases is to relieve obstructions 
 both mechanical and vaso-motor, to the proper circulation of 
 the blood. 
 
 The mechanical obstructions come from visceral displace- 
 ments; the vaso-motor disturbance, from some mal-adjust- 
 ment of structures in relation with, origin of, or along course of 
 the nerves, either cerebro-spinal or sympathetic, supplying the 
 uterus. Bony lesions, muscular contractures or relaxation 
 and abnormal conditions of the ligaments, produce most of the 
 vaso-motor disturbances. 
 
 LACK OF CARE on the part of the patient, such as ex- 
 posure during menstruation, and overwork, both physical and 
 mental, at the TIME OF PUBERTY, are common exciting causes 
 of female diseases. At the menstrual period there are vascular 
 and nervous changes taking place which, if interfered with, will 
 be the cause of various chronic uterine troubles. During puberty, 
 the development of the uterus and its appendages takes place, 
 and if the nerve force that should be used for their development 
 is directed into other channels, by mental or physical over-work, 
 the pelvic organs suffer. 
 
 PHYSIOLOGY The proper performance of the function 
 of the parts is necessary to health, and any condition perverting 
 the normal functioning would result in disease. In this class
 
 10 DISEASES OF WOMEN. 
 
 are included the barren, and especially those who deliberately 
 prevent or destroy the products of conception. The FUNCTION 
 of these organs is REPRODUCTION, and if the function is not per- 
 formed there will be a disturbance of the health of the organs; 
 for instance, fibroid tumors are usually found in nullipara above 
 the age of thirty; again, those who DELIBERATELY prevent con- 
 ception by the various artificial means, interfere with nature 
 and impair the whole nervous system. Nature will not stand 
 tampering with without rebelling, and there is a penalty for every 
 infringement. The least interference with her laws results in 
 disorders which vary with the amount of interference. 
 
 IN THE TREATMENT of diseases peculiar to women, the 
 perverted physiology is relieved in two ways; first, proper care 
 on the part of the patient; second, correction of anatomical 
 derangements. If the bony framework is properly adjusted 
 health will follow in most cases. 
 
 The bony lesion is usually primary, sometimes secondary. 
 Abuse of function will result in anatomical changes. By the 
 treatment and correction of these anatomical derangements, 
 which is hard to do in some cases, some good effect on the viscus 
 that is diseased or abused can be obtained. For example, ovarian 
 colic will produce contracture of muscles in the back. By over- 
 coming this contracture by inhibition, which is not possible in 
 many cases, the pain can be relieved. The trouble is, in such 
 cases, the effect not the cause is treated, and on this account 
 little can be done with such contractures, and that only tempo- 
 rarily. 
 
 The ANATOMY of the organs themselves; the neighboring 
 structures and tissues; the nerve supply to and from the organ; 
 the blood supply and lymphatic circulation are considered. To 
 the osteopath the bony framework in which the pelvic viscera
 
 INTRODUCTION. 11 
 
 are located, is the most important ; and on this account special 
 attention should be given to the lesions affecting the sacrum, 
 iliac bones, lumbar vertebrae and the coccyx. In addition, 
 uterine displacements should be corrected, since obstruction, to 
 nerve force, congestion, or even inflammation results from them, 
 which things cause varied and complex troubles; contractured 
 muscles relaxed, whether the result of thermic influence or of a 
 bony lesion ; and lesions affecting nerve centers of the uterus are 
 adjusted, since such impair their function. The NERVE CENTERS 
 need very little artificial stimulation if their connection with the 
 brain and uterus is not interrupted, since the body is a SELF- 
 RUNNING MACHINE. The rules of hygiene and dietetics should be 
 followed in these as well as in other diseases; that is, advise the 
 patient to take plenty of outdoor exercise and permit her to eat 
 anything that agrees with her, but caution her against excesses 
 along this line.
 
 12 DISEASES OF WOMEN. 
 
 DEVELOPMENT OF THE FEMALE GENITAL ORGANS. 
 
 SOME KNOWLEDGE of the origin and development of the 
 female genital organs is necessary to a proper understanding of 
 the conditions in which they have failed to attain the normal; 
 as in errors of development such as are exemplified in uterus 
 bicornis, infantile ovary or uterus and atresia of some parts of 
 the genital tract. 
 
 THE DATE of first appearance of the genital organs is 
 about the sixth week. The first organs to appear are the 
 Wolffian ducts, one on each side of the body. Originally they 
 are solid cords but afterward become hollowed out so as to form 
 tubes. Shortly after the Wolffian ducts have begun to develop, 
 the Wolffian bodies appear. From the external surface of each 
 Wolffian body a structure develops, known as the genital gland, 
 which subsequently becomes either a testicle or an ovary. The 
 two sexes cannot be differentiated before the eighth week. At about 
 the tenth week the external genital organs show a change mak- 
 ing it possible to differentiate between the sexes. In the male, com- 
 mencing at that time, the slight prominence which marked the 
 site of the external organs enlarges quite rapidly. In the female, 
 the upper end of the Wolffian body is attached to the diaphragm, 
 the lower, to the inguinal region by a ligament, which ultimately 
 becomes the round ligament of the uterus. This is of interest 
 because it shows that the round ligaments are not in reality lig- 
 aments, but consist of tissue almost identical with that forming 
 the uterus. From the Wolffian body is also developed the or- 
 gan of Rosenmuller or the parovarium.
 
 DEVELOPMENT. 
 
 13 
 
 6 XT 
 
 FIG. 1. Development of thegenito-urinary system. 1, 2, bladder; 3, clitoris; 4, sinus 
 
 uro-genitalis; 5, Muller's ducts; 6, 14. Wolffian bodies; 7, 11, Wolfflan ducts; 
 
 8, ovaries; 9, ends of Wolfflan ducts; 10, opening of ducts into the sinus 
 
 uro-genitalin; >2, urethra; 13, urachus. 
 
 OVARIES. The point to be considered in the development 
 of the ovary, is its descent. Originally, the ovary is develop- 
 ed in connection with the kidneys, and as it increases in size it 
 descends, and on this account the blood vessels and nerve fibers 
 supplying it are lengthened. In case of ovarian diseases then, 
 we would expect the lesion to be in the lower dorsal region. The 
 ovary ^undergoes great changes in shape; at first it is an elon-
 
 14 DISEASES OF WOMEN. 
 
 gated FLATTENED body, but later it changes its shape so that a 
 transverse section has the appearance of a BEAN, and finally it 
 becomes ALMOND SHAPED. 
 
 In the early stages the ovary is represented by a mass of 
 cells developed from the peritoneal covering of the Wolffian 
 body, but soon a protuberance of connective tissue enters from 
 behind into this cell mass. From this we find that the elements 
 entering into the structure of the ovary are the cells which form 
 the parenchyma or glandular element, and the connective tissue 
 or stroma. From this cell mass the ova are developed. Their 
 number is enormous, it having been estimated that the twe 
 ovaries together contain above seventy-two thousand. 
 
 THE MULLERIAN DUCTS. Shortly after the appearance 
 of the Wolffian bodies, there appears about the twelfth week, 
 a funnel-shaped invagination from the endothelium of the peri- 
 toneum at the inner side of the Wolffian bodies, which develops 
 into the Mullerian ducts, and is fastened to these bodies by a 
 mesentery. After the bodies disappear , this invaginated portion 
 becomes attached to the posterior abdominal wall and finally, 
 in the fully developed body, it forms a part of the broad liga- 
 ments of the uterus. 
 
 From that part of the Mullerian ducts which lies above the 
 insertion of the round ligaments of the uterus, are formed the 
 FALLOPIAN tubes; from that part below, together with the lower 
 end of the Wolffian duct, the genital cord or UTERUS. The tissue 
 that separates these ducts is absorbed and the septum disappears 
 in the lower two-thirds, thus forming the cavity of the uterus. 
 The insertion of the round ligament indicates the point of divi- 
 sion between the tube and the uterus. The fifteenth week wit- 
 nesses the fusion of the Uterine horns and the formation of the 
 cervix, enlargement of the perineum and development of the
 
 15 
 
 DEVELOPMENT. 
 
 vagina. Sometimes these Mullerian ducts fail- to coalesce, that 
 is, the partition is not absorbed, and from this arises the condi- 
 tion of uterus bicornis or uterus bifida. In the new born child
 
 16 
 
 DISEASES OF WOMEN. 
 
 the cervix is nearly twice as long as the body of the uterus 
 
 FIG. 3. Uterus bicornis 
 
 and its walls very much thicker. Sometimes this condition 
 exists after puberty and the name "infantile uterus" has been 
 applied to such condition. If on local examination of a woman 
 above the age of puberty the cervix is very small, it is a diseased 
 condition dependent upon error in development, or a lesion re- 
 sulting from an accident at puberty which affected the nutrition 
 center for the uterus. 
 
 During the first ten or twelve years of a child's life the 
 uterus is physiologically dormant; but at the approach of men- 
 struation the organ undergoes great vascular changes with a 
 marked increase in size, which continues until the rest of the 
 body has attained its limit of growth. In Fig. 4 the female ex- 
 ternal organs of generation of an adult are shown.
 
 AX ATOMY. 
 
 17 
 
 FIG. 4. The vulva, the external female organs 
 of generation. (Gray.)
 
 18 DISEASES OF WOMEN. 
 
 THE ANATOMY. 
 
 DIVISION OF THE GENITALIA. The genitalia are divided 
 into the external and internal organs. The former with the 
 vagina, form the organs of copulation; the latter, the repro- 
 ductive organs proper. To the external genitals belong the 
 mons Veneris, the vulva and the vagina; to the internal, the 
 uterus, Fallopian tubes and the ovaries. The vagina is really 
 the connecting link between the external and internal genera- 
 tive organs and belongs to neither, but is usually classed with 
 the external organs. 
 
 THE MONS VENERIS is a cushion of fat which covers the 
 pubes. It is covered with short crisp hairs which serve to pro- 
 tect from injuries and perspiration, the more delicate parts 
 which lie posterior to it. In cases of threatened abortion or 
 hemorrhage from the uterus, stimulation produced by a quick 
 jerk of these hairs of the mons Veneris, will usually stop the abor- 
 tion or hemorrhage by causing contraction of the circular mus- 
 cle fibers of the cervix. There are numerous nervous fibrils 
 which terminate in the mons Veneris, also a part of the round 
 ligaments. It also contains many sebaceous and sweat glands. 
 
 THE LABIA MAJORA. The labia majora are two masses 
 of tissue which surround the entrance to the vagina, uniting 
 behind just anterior to the anus in the posterior commissure or 
 fourchet, and in front in the mons Veneris; being analagous to 
 the scrotum in the male. They are less prominent after child- 
 bearing, and during old age they often present a SHRIVELLED 
 appearance. These folds are covered with short hairs which 
 are continuous with those covering the mons Veneris. Numerous
 
 ANATOMY. 
 
 19 
 
 sebaceous glands are found which secrete a fluid which serves to 
 moisten and lubricate the internal surface. 
 
 F 
 
 FIG. 5. External genitalia of niiiltiparous 
 woman, lifbia in contact. (Williams). 
 
 The inner surface is rose-color and forms a transition from 
 skin to mucous membrane. In the adult nulliparous woman, 
 the lower edges of the labia majora are in contact; cover all the 
 other parts of the vulva and form a line running in an antero- 
 posterior direction, called the RIMA PUDENDI. In a parous woman 
 these lips are slightly separated. The pudendal sac also lies un- 
 der this covering, and contains erectile fibers. 
 
 The CANAL OF NUCK, which is a prolongation of the peri- 
 toneum ACCOMPANYING the round ligament, is found under the 
 pudendal sac, w T hich sac is attached to the external inguinal ring. 
 In the aged there sometimes exists a flabby condition of these
 
 20 
 
 DISEASES OF WOMEN. 
 
 greater lips, and separation results, leaving the nymphse, as well 
 as a part of the vaginal canal, exposed. 
 
 The point of union posteriorly, is just anterior to the anus 
 and is very frequently lacerated during the first labor, unless 
 care is used by the accoucheur. On either side the round liga- 
 ments are inserted into upper part of lips. 
 
 THE LABIA MINORA OR NYMPHS. The labia minora 
 are two triangular folds of fine skin which lie between the labia 
 majora, becoming much more prominent anteriorly. They are 
 also called nymphge because they were supposed to direct the 
 
 Km (i Extern ill jj'fiiitalla of multiparous wo- 
 niiin, labiii spread apart. (Williams..) 
 
 course of the stream of- urine. Anteriorly they bifurcate form- 
 ing two folds; one going above the clitoris and forming its 
 prepuce; the other below forming the frenulum. Posteriorly
 
 ANATOMY. 21 
 
 they sometimes extend to the median line, thus forming a com- 
 plete ring inside; but more commonly they extend but half 
 way back blending with the labia majora. When they extend 
 to the median line they assist in the formation of the fourchet. 
 Sometimes there exists a non-developed condition of these two 
 folds, as a result of which they do not separate or in other cases 
 as a result of inflammation, adhesion occurs, both of which result 
 in a hooded clitoris, which condition is a cause of various re- 
 flex nervous disorders. "In the Bush-women of South Africa 
 the labia minora become very long and extend in some cases, 
 as far as the knees; this condition being known as the Hot- 
 tentot apron." 
 
 In the NEW BORN CHILD, the labia minora extend beyond 
 the labia majora on account of the non-developed condition of 
 the greater lips. The lesser lips in the adult are very copiously 
 supplied with sebaceous and mucous glands, and during sexual 
 excitement, they taking part in the sexual act and being abundant- 
 ly supplied with sensory nerves, their secretions are markedly 
 increased. 
 
 The labia majora contain no fat but here are located LARGE 
 VENOUS plexuses and bulb-shaped terminal nerve organs. In 
 case of masturbation, the lesser lips are very red and irritable. 
 There is often discovered on them a yellowish deposit. They 
 are usually hypertrophied in cases of chronic masturbation while 
 the greater lips are atrophied. Sometimes hystero-epilepsy re- 
 sults from irritation or inflammation of these lips; such being 
 the condition in a case treated by the author in which the least 
 irritation would bring on an attack and in which case they were 
 hypertrophied and hypersensitive. 
 
 THE CLITORIS. The clitoris is an erectile organ which is 
 the homologue of the male organ, the penis, but differs from it in
 
 22 DISEASES OF WOMEN. 
 
 that it does not possess a corpus spongiosum and is not tunnelled 
 by the urethra. It is composed of two corpora cavernosa and 
 the GLANS CLITORIDIS. It is held in position by a suspensory liga- 
 ment, attaching it to the lower border of the symphysis pubis. 
 It forms a landmark for the location of the meatus urinarius 
 which is located about one inch posterior to it. 
 
 During the non-erectile state, only the glans clitoridis is 
 visible; but during the erectile stage the two crura which unite 
 to form the clitoris proper, can be clearly outlined and have the 
 appearance of an inverted "V." The glans clitoridis contains 
 papillae occupied by arterial tufts, and the special peculiar nerve 
 endings, the GENITAL CORPUSCLES. There is an intimate con- 
 nection between the CLITORIS AND THE NIPPLES; both being com- 
 posed of erectile tissue. Stimulation of the nipples will cause 
 contraction of the uterus and erection of the clitoris. The cli- 
 toris is the chief seat of voluptuous sensation and in cases in which 
 masturbation has been practiced the glans clitoridis will be found 
 red, irritable and sometimes inflamed. 
 
 A recent writer claims that the meatus urinarius instead 
 of the clitoris is the seat of voluptuous sensation. He says, 
 "In the male the orgasm results from the passing of jets of semen 
 over the mucous membrane of the urethral canal; in the female, 
 by jets of mucus from the neck of the bladder through the urethra." 
 
 As mentioned above, this organ may be hooded; adhesions 
 may exist; or it may be in a condition of non-development, 
 either of which may seriously interfere with the nerve force of 
 the body. Stimulation of this organ produces CONTRACTION of 
 the cervix uteri, while INHIBITION produces RELAXATION. This 
 is explained by the fact that the pudic nerve which supplies the 
 clitoris, connects with and is derived from the same source that 
 the nerves which supply the cervix, viz: the sacral nerves from
 
 ANATOMY. 
 
 23 
 
 the sacral segments of the spinal cord. Since the CEREBRO- 
 SPINAL nerves predominate in the cervix, and the SYMPATHETIC 
 in the fundus and body of the uterus, the above connection is 
 the more readily understood. Advantage is taken of this by 
 the osteopath in the treatment of dysmenorrhea due to the con- 
 traction of the cervix lessening the calibre of the os; also the 
 first stage of labor, INHIBITION of THE CLITORIS in both cases 
 dilating the os. Inhibition at the SACRO-ILIAC SYNCHONDROSES 
 has a similar effect: the sacral nerves being directly reached at 
 these points. 
 
 The BLOOD SUPPLY of the clitoris comes from the internal 
 pudic by way of the dorsal arteries of the clitoris and the artery 
 
 Vestibula'r 
 bulbs 
 
 Vagina 
 
 FIG. 7. Preparation showing clitoris and its vascular 
 supply. (Modified from Clirobak and Rosthorn, by Williams.) 
 
 of the corpus cavernosum. The VEINS accompany the arter- 
 ies; the DORSAL VEIN of the clitoris being the principal one. This
 
 24 DISEASES OF WOMKX. 
 
 vein is the homologue of the dorsal vein of the penis and is one 
 of the principal factors in erection. 
 
 THE NERVE SUPPLY comes from the dorsal nerve of the cli- 
 toris which is the termination of the PUDIC NERVE. This nerve 
 terminates in corpuscles and very abundantly supplies the or- 
 gan. These terminal nerves are relatively better developed and 
 are found in greater numbers, than the corresponding ones in 
 the penis. LESIONS of the lower dorsal region will affect this 
 nerve, causing either stimulation or inhibition, that is, increas- 
 ing or decreasing, even destroying, sexual desire. 
 
 Williams says" About the middle of the last century Baker 
 Brown proposed the amputation of the clitoris as a panacea for 
 nearly all ails to which women are subject, and for a short time 
 the operation of clitoridectomy enjoyed a marked vogue but has 
 since become completely abandoned." 
 
 Among many of the aboriginal races the same operation 
 has been performed from time immemorial as a religious rite and 
 was designated as "girl circumcision." 
 
 VESTIBULE. The vestibule is a triangular space situated be- 
 tween the lesser lips, bounded anteriorly by the crura of the clitoris 
 and posteriorly by the opening of the vagina. Some writers 
 include with it the fossa navicularis, and define the vestibule as 
 an almond-shaped area which is enclosed between the labia minora 
 and extends from the clitoris to the fourchet. The FOSSA NAVI- 
 CULARIS is seldom observed in parous women since it is usually 
 obliterated by childbirth. Near the center is found the meatus 
 urinarius, and just below the meatus is a little mucous elevation, 
 which is a guide to the introduction of the catheter when in 
 spection is not used. 
 
 Extending from the clitoris along either side of the vesti- 
 bule are TWO LARGE OBLONG MASSES about one inch in length,
 
 ANATOMY. 
 
 25 
 
 consisting of a plexus of veins enclosed in a thin layer of fibrous 
 membrane. These bodies are called BULBI VESTIBULI or BULBS 
 or THE VAGINA, and are analogous to the bulb of the corpus 
 spongiosum of the male; they being regarded as the cleft homo- 
 logue of the corpus spongiosum. The CONSTRICTOR VAGINAL 
 MUSCLES lie in relation with these bulbs and by their CONTRAC- 
 TION, as during sexual excitement, these venous plexuses are 
 
 COMPRESSED AND THE TISSUES BECOME ERECT. Repeated SCXUal 
 
 excitement causes a WEAKENING OF THESE MUSCLES and the walls 
 of these veins are dilated and diseased conditions follow. These 
 are shown in Fig. 8. 
 
 FIG. 8. The bulbs of vestibule. . Bulb of vestibule: b, ruuscular tissue of va- 
 gina; c, d, e, f, the clitoris and muscle*; g. h. i, k, 1, in, n, veins of the nymphae 
 and clitoris communicating with the epigastric and obstructor reins. (Jewett). 
 
 Sometimes these veins become enlarged from other causes 
 and a tumor is formed, which becomes very painful in some
 
 26 
 
 DISEASES OF WOMEN. 
 
 cases. Mucous follicles are located over the vestibule and secrete 
 mucus very freely under any persistent irritation. 
 
 BARTHOLIN'S GLANDS. On either side of the commence- 
 ment of the vagina and behind the hymen are found two bean- 
 shaped, round or oblong bodies, which are analogous to Cow- 
 per's glands in the male; these are called the glands of Bartholin 
 and are shown in Fig. 9. They are muco-serous glands and pour 
 
 VULVO-VAGINAL 
 GLAND 
 
 FIG. 9. The vulvo vaginal gland or gland of Bartholin. The dotted line indi- 
 cates the limits of the bulbs of the vagina. (Testut). 
 
 their secretions upon the mucous membrane by long slender 
 ducts which open just external to the hymen. These ducts often 
 harbor gonococci which gain access to the gland and set up sup- 
 puration. The greater lip becomes distended with pus and if 
 not opened up, will break on its inner and lower aspect. Such 
 abscesses are common in prostitutes. Other cases of abscess 
 of Bartholin 's glands result from trauma. 
 
 TheTglands constantly secrete a glairy fluid, but dur-
 
 ANATOMY. 27 
 
 ing sexual excitement this secretion is enormously increased. 
 They are supposed to be affected in cases of sexual debility and 
 in cases in which there is a flabby condition of the vulva or lower 
 abdominal wall. Sometimes in cases of difficult labor, INHI- 
 BITION OF THESE GLANDS and the nerves in relation, will cause 
 dilatation of the vagina by relaxing the perineum. The sphinc- 
 ter vagina and LEVATOR ANI MUSCLES are the PRINCIPAL factors 
 that control the tone of the pelvic floor. 
 
 There are numerous small mucous secreting glands called 
 GLANDULAE VESTiBULARES MiNORES which open into the vesti- 
 bule. These when normal, keep the vulva quite thoroughly 
 moistened and lubricated. Their secretion, like that of Bartho- 
 lin's glands, is increased by sexual excitement. 
 
 HYMEN. The hymen is a MEMBRANOUS FOLD containing 
 a few connective tissue fibers, blood vessels and nerve filaments, 
 which closes to a greater or lesser extent, the entrance to the 
 vagina, or ostium vaginae. This membrane is usually perforated 
 by one or more openings through which escapes the menstrual 
 flow. The opening is usually crescentic in shape with the con- 
 cavity looking upward Sometimes it is circular, or the mem- 
 brane may be perforated with many small openings, to which 
 is given the name of CRIBIFORM hymen. 
 
 In the new born baby the opening is very small and some- 
 times obscure. If an IMPERFORATE condition exists, and it 
 causes no particular disturbance, wait until puberty before 
 rupturing it, but if nervous symptoms develop without any other 
 apparent cause, the membrane should be perforated. 
 
 In STRUCTURE it is the same as the walls of the vagina, with 
 some modification as mentioned above, since the vaginal walls 
 unite below to form this membrane. Several TYPES, regarding
 
 28 
 
 DISKASKS OF WOMEN. 
 
 thickness, have been observed, ranging from a delicate struc- 
 ture resembling a spider's web to a fleshy ligamento-cartilagin- 
 
 ^"TSSSV-V^ 
 
 miS^i^^rjm m*&^:^%% 
 
 FIG. 10. Different forms of hymens . 
 
 ous membrane. In some it ruptures on the slightest pressure, 
 in others an operation, by which an artificial opening is made, 
 is necessary before a digital examination is possible.
 
 ANATOMY. 20 
 
 Sometimes at puberty the hymen is imperforate and amen- 
 orrhea or rather concealed menstruation exists. 
 
 After, rupture the edges cicatrize and the hymen becomes 
 permanently divided into several portions, called CARUNCULAE 
 MYRTIFORMES. The extent of rupture varies with the struc- 
 ture of it. It is generally believed by the laity that the rupture 
 is associated with hemorrhage, but this is by no means always 
 the case, though in rare instances there is a profuse hemorrhage 
 resulting in anemia. The hymen is usually ruptured at first 
 coition, and on this account it is of medico-legal interest; how- 
 ever, it may persist after copulation, so its condition cannot be 
 considered as a reliable test of virginity. 
 
 Care should be taken in the examination of a young girl 
 that the hymen be not ruptured; in fact, it is seldom necessary 
 to make a local examination of a virgin, and should be avoided 
 as long as possible. Labor usually destroys the hymen and all 
 that remains are several protuberances, which form a serrated 
 ring around the ostium vaginae. These remains, whether due to 
 childbirth, coition or forcible examination, do not always heal 
 readily but remain irritable and produce vaginismus and dys- 
 pareunia. Forms of nervous affections also are attributed to 
 this pathological condition of the hymen. 
 
 THE FOURCHET. The fourchet is a thin fold of skin form- 
 ed by the junction of the posterior ends of the labia majora; 
 sometimes the minora. It encloses a boat-shaped depression, 
 which is called the fossa navicularis. The point of. interest re- 
 garding it is, that it is either very badly bruised, or lacerated at 
 the first parturition. 
 
 THE VAGINA. The vagina is a MUSCULO-MEMBRANOUS 
 CANAL which connects the uterus with the vulva. It is con- 
 tinuous above with the cervix, with which it forms the vaginal
 
 30 DISEASES OF WOMEN. 
 
 vault or fornices, and below, with the hymen. The FORNICES 
 are divided into the lateral, anterior and posterior from their 
 relation to the cervix uteri. Their size depends on position, 
 length and thickness of the cervix; degree of distention or bal- 
 looning of the vagina; and the presence or absence of growths. 
 The AXIS OF THE VAGINA forms an angle of about sixty degrees 
 with the horizon, and in its lower portion is about parallel with 
 the conjugate diameter of the brim of the pelvis, while the upper 
 end presents a concavity corresponding to the curve of the sac- 
 rum. It has two walls, one anterior and one posterior, which 
 are HELD IN APPOSITION, principally, BY THE MUSCLES OF THE 
 PELVIC FLOOR, thus enclosing AN AIR TIGHT CAVITY the true 
 pelvic cavity. The cavity of the vagina, which is formed by 
 separation of the walls, is cone-shaped with the base above and 
 its apex at the hymen; in other words, the cavity is shaped like 
 an inverted cone. This is best ascertained by admitting air 
 into the vagina when the patient is in the knee-chest position. 
 
 "These Walls are composed of three structures; externally, 
 a fibrous sheath, internally, a mucous membrane, and between , 
 there is a double layer of muscles, the fibres of the outer being 
 longitudinal, the inner, circular." The posterior wall is slightly 
 longer than the anterior, being about three and a half inches in 
 length; while the anterior wall is about two and a half inches. 
 The anterior wall is intimately blended with the urethra and 
 trigone of the bladder, thus any displacement of this wall 
 such as occurs in cystocele, interferes with the function of the 
 above mentioned organs. 
 
 The vagina is CAPABLE OF GREAT DISTENTION, with power 
 to return to normal without loss of integrity. On transverse 
 section it has the appearance of an "H." The walls are covered 
 with mucous membrane which, in a normal subject and in vir-
 
 ANATOMY. 
 
 31 
 
 gins, and especially those of the colored race, is thrown into trans- 
 verse folds or rugae. These rugae aid in 
 promoting sexual excitement and con- 
 tribute to vaginal enlargement in pa~- 
 turition. Absence of these rugae is in- 
 dicative of RELAXATION, due to disease 
 or over-distention, AND LEADS TO PRO- 
 LAPSUS, not only of the VAGINAL WALLS 
 such as rectocele and cystocele, but of 
 THE UTERUS. Near the uterus, the 
 vaginal walls are composed principally 
 of contractile and erectile tissues. The 
 HEALTHIER the VAGINA is, the greater the 
 contractile and erectile power, and 
 the better the uterus is supported. At 
 the lower extremity of the vagina is found 
 a thin band of voluntary muscle called 
 the sphincter vagina, which assists in 
 closing the lumen of vagina. However, 
 n the levator ani muscle is the real sphinc- 
 
 FIG. ll-Anterior wall of tgr Q f tne va m lla s i nce bv its COntraC- 
 vagina, showing eolumnae 
 
 rugarum (Savage.) i, 2, tion, the posterior wall of the vagina is 
 
 anterior columns of the va- . . . 
 
 gina; n, ureterai orifice; m, tightly drawn against the anterior, v an- 
 ous glands are here located which se- 
 crete an acid mucus, which acts as a barrier to the pass- 
 ing of micro-organisms into the uterus. DOUCHES frequently 
 indulged in either wash away or neutralize this acid mucus and 
 CAUSE A WEAKENING of nature's defenses against the inroads of 
 disease. Sometimes this secretion is increased in quantity to 
 such an extent that it is abnormal, and if it also changes in quality 
 it is called leucorrhea.
 
 32 
 
 DISEASES OF WOMEN. 
 
 The vagina has a TRIPLE PHYSIOLOGICAL function. During 
 copulation it receives the penis; during parturition it acts as a 
 protection to the child and helps move it along the curve of 
 Carus; and the above mentioned power of the normal vaginal 
 secretion to kill bacteria, and thus prevent infection of the in- 
 ternal organs. In cases in which there is a weakness of the mus- 
 cles of the pelvic floor, the va- 
 ginal walls tend to separate, and 
 on account of this, various uterine 
 displacements are likely to occur. 
 Normally, the walls fit together 
 so accurately that during copu- 
 lation, or the making of a local 
 vaginal examination NO AIR EN- 
 TERS THE PELVIC CAVITY, Unless 
 
 the posterior wall is drawn con- 
 siderably backward, thus bal- 
 looning the vagina. 
 
 A lesion of the sacrum, lower 
 dorsal and lumbar vertebrae, es- 
 pecially the fifth lumbar, or at 
 sacro-iliac synchondrosis will 
 affect the innervation of the floor 
 
 FIG. 12. Horizontal section of pel- , , j 
 
 vicfloor near pelvic outlet, showing AND IT SINKS downward and 
 
 vaginal and rectal slit., <Henle)Ua. bkward ^^ sepfirat ing the 
 urethra; Va , vagina; It , rectum; La , 
 
 levator ani. ^ wo vaginal walls. When this 
 
 occurs, air will enter the cavity which is normally air-tight, 
 and this destroys the equilibrium of the pelvic contents. These 
 points are of special interest to the osteopath in the treatment 
 of prolapsus of the uterus, and are anatomically explained by 
 the fact that the above mentioned lesions affect the pudic and
 
 ANATOMY. 
 
 33 
 
 sacral nerves which supply the pelvic floor. These lesions pro- 
 duce either increased tone or atony, usually the latter. 
 
 The. arteries come from the anterior division of the internal 
 iliac or one of its branches, which include the vaginal, uterine, 
 middle hemorrhoidal, vesical and internal pudic. The lower part 
 gets the middle hemorrhoidal and internal pudic, the middle 
 part the vesical and the upper part, the cervico-vaginal branches 
 of the uterine. The veins form a plexus around the vagina from 
 which spring the venae comites which empty into the pudic, 
 thence into the internal iliac. The vaginal veins communicate 
 with those draining the labia, bulb, bladder, uterus and rectum, 
 which fact furnishes an explanation for many of the complica- 
 tions of uterine and rectal vascular disturbances. The lympha- 
 tics, from the lower third of the the vagina , empty into the IN- 
 GUINAL LYMPHATIC GLANDS; those from the middle third, into 
 the HYPOGASTRIC, while those from the upper third empty into 
 
 Fie. 13. Anterior aspect of uterus, 
 (Williams.) 
 
 FIG 14. Posterior aspect of uterus, 
 (William*.) 
 
 the the ILIAC GLANDS. The nerves come from the sympathetic 
 
 3
 
 34 
 
 DISEASES OF WOMEN. 
 
 vaginal plexus, most of which terminate in end bulbs. A prac- 
 tical point might be mentioned here in regard to the way a great 
 many people sit. Instead of sitting on the tuber ischii, the 
 WEIGHT of the body is supported by the SACRUM, and this inter- 
 feres with the nerve force to the pelvic organs by PRESSURE ex- 
 erted on the PUDIC nerve at the point where it loops around the 
 spine of the ischium. 
 
 THE UTERUS. The uterus is a pear-shaped body which 
 is located in the true pelvis, with the larger 
 end upward. It is bounded anteriorly and in- 
 f eriorly by the bladder ; superiorly by the SMALL 
 INTESTINES; and posteriorly by the RECTUM. 
 It is divided into two parts, the . BODY OR 
 CORPUS and the CERVIX OR NECK, a constric- 
 tion corresponding to the internal os, being 
 the line of division. The body is divided into 
 the BODY proper, which is that part included 
 between the cervix and entrance of the Fal- 
 lopian tubes, and the FUNDUS, which is that 
 part located above the entrance of the Fallo- 
 pian tubes. 
 
 FIG )5. Lnteral view J 
 
 of uterus, showing IT IS A FREELY MOVABLE ORGAN, being 
 
 supra-vagiual and in- 
 
 fra-vaginal portions anchored by elastic ligaments. It is moved 
 
 of cervix and arrange- . , . . it i_t jj cii j -J.-L. 
 
 mnt of peritoneal backward when the bladder is filled with 
 covering (Williams.) 
 
 urine and forward, when the rectum is dis- 
 tended. Its LENGTH varies, the average being about three and 
 one-half inches. The relation between the length of the body 
 and cervix varies greatly; in a YOUNG GIRL the BODY is ONLY 
 
 HALF THE LENGTH OF THE CERVIX ; in YOUNG VIRGINS the two are 
 
 of about EQUAL LENGTH while in MULTIPAROUS WOMEN the cer- 
 vix is little more than ONE-THIRD of the total length of the
 
 ANATOMY. 
 
 35 
 
 uterus. The PAROUS uterus is from a third to half larger than 
 the virgin uterus. After the menopause all the dimensions are 
 decreased. 
 
 The portion of the cervix which extends into the vagina is 
 called the INFRA-VAGINAL PORTION, and that part above the 
 junction of the vagina and the uterus, is called the SUPRA- VAGINAL 
 portion. The infra-vaginal portion extends about an inch into 
 
 the upper part of the vagina 
 and can be encircled by the ex- 
 amining finger. This space or 
 cavity around the cervix has 
 been divided for convenience, 
 into the anterior, lateral, and 
 posterior fornices of the vagina. 
 Fig. 16 illustrates the relation 
 of the uterus to the vagina 
 and the location of the for- 
 
 Fig. 16 Showing junction of vagina 
 and cervix. 
 
 mces. 
 
 The lower portion of the cervix is CIRCULAR LIKE A ROUNDED 
 CONE and should feel SMOOTH and of about the consistency of 
 the end of the nose. It is pierced in the center by an OPEN- 
 
 Fio. 17. Virginal exter- 
 nal os. (Williams ) 
 
 FIG. is. Parous external 
 os. (Williams.) 
 
 ING, felt as a dimple in nullipara, as a transverse slit in multi-
 
 36 
 
 DISEASES OF WOMEN. 
 
 para, which is the os externum. The external os varies greatly 
 as to size and appearance. In the virgin it is small and oval- 
 shaped resembling a tench's mouth, hence the name os TINCAE. 
 After labor it becomes converted into a transverse slit with 
 changes that are so characteristic, that one can determine with 
 a fair degree of accuracy whether the woman has ever been 
 pregnant. If this slit were extended, it would divide the cer- 
 vix into an anterior and a posterior 
 lip; the POSTERIOR appearing to be 
 longer on account of the posterior 
 fornix being deeper than the an- 
 terior. Normally the cervix is 
 HARD, it being composed, in part, 
 of connective tissue in which are 
 found many non-striated muscle 
 fibers which are circular; also 
 ELASTIC tissue is present, this per- 
 mitting of GREAT DISTENTION. If 
 it is found to be SOFT, it indicates 
 
 FIG. 19 -Reconstruction of uterus a DISEASED CONDITION OR PREG- 
 showing shape of uterine cavity and NANCy j n con ditions of SuMn- 
 cervical canal. (Williams.) 
 
 volution the os is usually PATULOUS. In cases in which the 
 cervix is lacerated, it is IRREGULAR with roughened elevations 
 which are the result of inflammation of the Nabothian glands. 
 These glands undergo a caseous or cystic degeneration and 
 when this takes place, the name NABOTHIAN CYSTS is given 
 them. They feel like SHOT IMBEDDED IN THE CERVIX. 
 
 During infancy and in the infantile types of uteri, the cer- 
 vix constitutes as stated before, the larger part of the uterus, 
 and is situated very high in the pelvis. After the menopause 
 the cervix undergoes a fibrous degeneration, it feeling like a
 
 ANATOMY. 37 
 
 cartilaginous ring, and becomes so shortened that in many cases, the 
 
 Fig. 20 Sagittal section through body of newly born child. (Williams.) 
 
 vagina finally terminates in the os uteri without any palpable 
 projection of the cervical portion into the vagina. 
 
 The body is TRIANGULAR in appearance and has three open- 
 ings; one below, the os of the uterus; and two above, one at eithe 
 corner formed by the entrance of the Fallopian tubes. It is 
 flattened antero-posteriorly ; the anterior and posterior surfaces 
 being free, while the broad ligaments obscure the outline of the 
 edges. The FALLOPIAN TUBES are attached to each upper corner 
 of the uterus; immediately below them is the attachment of the 
 ROUND LIGAMENTS and just beneath the round ligaments the 
 insertion of the ovarian ligaments. 
 
 The CAVITY of the uterus is small in comparison to its size.
 
 38 DISEASES OF WOMEN. 
 
 Its length is about two and a half inches. It is TRIANGULAR 
 
 Fig. 21 Sagittal section through adult woman (Kelley) reduced to same size as 
 Fig. 20 for comparison. (Williiims.) 
 
 in shape and connects with the various openings. At the 
 junction of the cervix and body is a slight constriction 
 which corresponds to the internal os. The endometrium of this 
 part and that of the cervix is so arranged that it has the ap- 
 pearance of an ARBOR VIT^E. These PALM.E PLICATE consist 
 of two ridges which run along the median line of the anterior and 
 posterior walls respectively and give off numerous lateral 
 branches. It is a curious coincidence that there is this branch- 
 like arrangement of the tissues in the womb, and that a some- 
 what similar arrangement exists in the cerebellum, the predom- 
 inate, central organ of the sexual instinct. 
 
 The mucous membrane lining the cavity of the uterus is
 
 ANATOMY. 
 
 39 
 
 called endometrium. It is a soft, thin, pinkish membrane which 
 is very intimately connected with the muscle fibers forming the 
 
 Fig. 22. Fetal uterus and va- 
 gina (Byford from Winkel.) o. In- 
 ternal on; v. 1 anterior lip; h. 1. 
 posterior lip. 
 
 Fig. 23. Infantile uterus. (Byford 
 from Winkel.) 
 
 uterine wall. In fact, it is so thin and so tightly and securely 
 attached that it is practically impossible to dissect it out. In 
 curettage, in which a sharp instrument is used, it is partly re- 
 moved and with it portions of the uterine wall on account of the 
 above mentioned facts. This membrane is perforated by ducts 
 of the numerous uterine glands. These GLANDS secrete a thin 
 ALKALINE FLUID, the function of which is, to lubricate the lining, 
 to keep the cavity moist, and to protect against the invasion of 
 micro-organisms. In normal cases cilia are present. The current, 
 produced by their action, according to Hofmeir, is now proven 
 to be from above downward instead of from below upward as 
 was once believed. 
 
 The walls are composed of three layers; the serous or peri- 
 toneal, muscular and a mucous coat. The muscular coat is also 
 divided into three layers; longitudinal, circular and oblique.
 
 40 DISEASES OF WOMEN. 
 
 The LONGITUDINAL FIBERS predominate in the fundus and re- 
 ceive their nerve supply principally from the SYMPATHETIC 
 nervous svstem, while the circular fibers predominate in the cer- 
 vix and are supplied almost entirely by CEREBRO-SPINAL nerves. 
 These two sets of muscle fibers are opposite in their action, that 
 is, when the fundus contracts the cervix relaxes, and when cer- 
 vix contracts the fundus relaxes. This is called POLARITY and 
 upon it depends, normal menstruation and parturition. The 
 OBLIQUE layer is arranged like the figure eight and the fibers, 
 winding around the blood vessels, thus form a ligature of them 
 during contraction of the uterus. 
 
 If the AXES of the uterus and the vagina were extended, they 
 would, in a theoretically perfect case, meet at right angles; how- 
 ever, this varies according to the distention of the bladder and 
 rectum. In the GENU-PECTORAL position the uterus, if in a nor- 
 mal position, will be in a PERPENDICULAR line, the heavy end or 
 fundus down. In treating the various displacements, especially 
 retro-deviations, advantage is taken of this, since the uterus, 
 when the patient is in this position, like a pendulum tends to 
 swing toward the perpendicular line, which is the normal posi- 
 tion, unless held out of position by adhesions. In a nulliparous 
 patient this treatment is first used if a displacement of the uterus 
 exists, which, if coupled with a "lifting up" manipulation of the 
 prolapsed bowels, is successful in most cases. 
 
 The CERVIX is regarded by some as a large mucous gland; 
 injury or disease of which produces an abnormal secretion or 
 leucorrheq. 
 
 The blood supply of the uterus is from two sources, the uterine 
 and ovarian arteries. The uterine comes from the anterior 
 division of the internal iliac, and after descending for a short 
 distance enters the base of the broad ligaments, crosses the
 
 ANATOMY. 41 
 
 ureter and reaches the side of the uterus. It divides just before 
 reaching the supravaginal portion of the cervix into two branches : 
 the SMALLER, or cervico-vaginal, supplies the lower portion of 
 the cervix and upper part of the vagina; the LARGER becomes 
 markedly convoluted and extends along the margin of the uterus 
 and gives off numerous branches which penetrate into its sub- 
 stance. It finally divides into three terminal arteries; the ovariar, 
 the tubal and one going to the fundus; the names indicating 
 their destination. PULSATION can be readily felt in these arteries 
 when they are congested, especially if there is metritis. 
 
 The OVARIAN is from the abdominal aorta. It enters the 
 broad ligament near the origin of the infundibulo-pelvic liga- 
 ment and from this part numerous branches go to the ovary. 
 The main stem traverses the entire length of the ligament and 
 supplies the fundus of the uterus, there anastomosing with the 
 ovarian branch of the uterine. ALL THE ARTERIES IN THE 
 
 UTERUS FRKELY ANASTOMOSE. 
 
 The VEINS are formed into plexuses around each artery. The 
 blood from the lower part reaches the internal iliac vein; that 
 from the ovary and upper part of the uterus and broad ligaments 
 is collected by a great number of veins which go to form a large 
 plexus, w r hich on account of its supposed resemblance to a ten- 
 dril is called the pampiniform plexus of veins. The ovarian vein 
 drains this plexus. The right ovarian terminates in the inferior 
 vena cava, the left in the renal; the former at an acute angle, the 
 latter at about a right angle. 
 
 The lymphatic vessels of the lower part of the uterus termi- 
 nate in the hypogastric glands, which are situated between the 
 hypogastric and external iliac arteries. The lumbar glands 
 drain the remaining part of the uterus. 
 
 The nerve supply is from two sources, cerebro-spinal and
 
 42 
 
 DISKASKS OK \V().\!K.\. 
 
 sympathetic. The anterior divisions of the second, third and 
 fourth sacral nerves largely supply the circular muscle fibers of 
 the cervix. The body is supplied almost entirely by the uterine 
 and ovarian plexuses; the uterine being derived from the pelvic 
 or inferior hypogastric plexus and sacral nerves and the ovarian 
 from the renal and aortic plexuses. Some authors speak of a 
 large cervical nerve ganglion, which lies to the side of, and be- 
 hind the cervix. 
 
 LIGAMENTS OF THE UTERUS. The LIGAMENTS of the 
 uterus are eight in number, two BROAD, two SACRO-UTERINE, 
 
 UTERO-SACRAL LIG'T. 
 
 URETER 
 
 OVARY 
 APPENDIX 
 
 UTERUS 
 
 FIMBRIAOF 
 FALLOPIAN TUBE 
 
 BLADDER 
 URACHUS 
 
 INSERTION OF ROUND LI GT. 
 FIG. 24 Superior view of pelvic viscera. 
 
 two ROUND, VESICO-, and RECTO-UTERINE, which serve to anchor, 
 rather than support, the uterus. Six of them are composed of
 
 ANATOMY. 43 
 
 folds of the peritoneum, the remaining two, the round ligaments, 
 are musculo-fibrous in structure. 
 
 All of them are more or less CONTRACTILE and ELASTIC, and 
 by osteopathic treatment these properties can be increased or 
 decreased. In the treatment of the various uterine displace- 
 ments, but particularly prolapsus, it is the aim of the physician 
 to restore tone to these ligaments, in fact, this must be accom- 
 plished before a cure can be effected. 
 
 The vesico-uterine ligament is a fold of peritoneum which 
 is attached, anteriorly to the bladder and posteriorly, to the 
 supra-vaginal portion of the cervix and lower part of the corpus. 
 Some authors speak of this fold of the peritoneum as an ad- 
 hesion, which term describes it more accurately than does the 
 term ligament. Its FUNCTION is to hold the lower part of the 
 uterus in position, that is to hold the uterus in relation with the 
 bladder. Its action is counteracted by that of the sacro-uterine 
 ligament. The two sacro-uterine ligaments SUSPEND the uterus 
 in the pelvic cavity and with the vesico-uterine form an axis 
 or fixed point, around which nearly all the uterine movements 
 take place. In distention of the bladder the body of the uterus 
 is forced backward and the cervix moves forward. The reverse 
 is true in impaction of the rectum. The uterus CANNOT DESCEND 
 unless the utero-sacral ligaments relax; it cannot rise without 
 relaxation of the anterior or vesico-uterine ligament. 
 
 One cannot better ascertain the nature, direction and ex- 
 tent of these movements than by provoking them by means of 
 the ringer in the vagina, by which pressure is exerted on cervix. 
 In pushing the cervix backward the fundus moves forward; in 
 pulling it forward the fundus goes backward ; in pushing or pulling 
 it to the right, the fundus is rotated to the left, and vice versa. 
 In short, the fundus, in a normal case, is always in an opposite
 
 44 DISEASES OF WOMEN. 
 
 direction to that of the cervix and is freely moved by the above 
 methods. In inflammatory conditions of the vesico-uterine lig- 
 ament, such as occur in local peritonitis complicating, or follow- 
 ing metritis, adhesions are likely to be formed which bind the 
 uterus to the bladder. As a result of this the bladder is irritated. 
 At first there is frequent micturition followed by, in pronounced 
 cases, a sort of spasm or tenesmus immediately after the com- 
 pletion of the act. 
 
 SACRO-UTERINE LIGAMENTS. The sacro-uterine liga- 
 ments are two folds of peritoneum which are attached to the 
 anterior surface of the second sacral, sometimes the first, or as 
 high as the fifth lumbar vertebra, and to the posterior surface 
 of the uterus on a level with the os internum. When the patient 
 is in the erect posture they are nearly vertical, which position 
 very materially assists in supporting the uterus. They are known 
 as the folds of Douglas and constitute the upper lateral boundary 
 of the pouch of Douglas and are the most important of all the 
 ligaments. They contain contractile fibers and are called the re- 
 tractor muscles of the uterus. Deaver describes them as flat 
 muscular bands which extend from the uterus at the level of the 
 internal os, beneath the layers of the recto-uterine ligament, to 
 the sides of the sacrum opposite the lower border of the sacro- 
 iliac articulation. Between the two ligaments passes the rectum, 
 as shown in Fig. 25. In distended conditions of the rectum 
 these ligaments are affected, that is, they are irritated and tend 
 to retract the uterus. These ligaments, working in conjunc- 
 tion with the round ligaments, hold the uterus in anteversion, 
 and if both are shortened, anteflexion will result. Also the 
 ligaments prevent the uterus from being pulled down very far, 
 and if there is a condition of prolapsus, the traction exerted upon 
 them by the weight of the uterus, will result in an irritation of
 
 ANATOMY. 
 
 45 
 
 the nerves which make their exit at the first, second and third 
 sacral foramina, hence the backache which usually accompanies 
 such conditions. These ligaments play a very important role 
 
 Fu; 2"). The utcro-siicrnl ligaments: showing relation 
 to rectum (After Testut). 
 
 in uterine displacements. If they retain their normal muscular 
 tone and contractile power, the uterus can with difficulty be dis- 
 placed. 
 
 The NERVE supply of THESE LIGAMENTS is very great on ac- 
 count of their structure, they being composed of peritoneum 
 and muscle fibers. It comes principally from the third and fourth 
 sacral nerves. Since these nerves also supply the pelvic floor
 
 46 DISEASES OF WOMEN. 
 
 and uterus, a disease of one part will affect the other. A lesion 
 affecting one will in time affect all. A relaxed vagina means a 
 relaxed condition of the sacro-uterine ligaments and thus furnishes 
 an almost infallible sign as to the condition of the uterus. 
 
 THE RECTO-UTERINE LIGAMENT. The RECTO- 
 UTERINE ligament is a fold of peritoneum which connects the 
 rectum with the lower part of the uterus and is really a part of 
 the sacro-uterine ligaments, it being enclosed by them. This 
 fold of peritoneum which is placed between the rectum and 
 uterus also helps to form the pouch of Douglas. Adhesions 
 sometimes exist between the two layers of peritoneum forming 
 the walls of the cavity, thus obliterating it and fixing the uterus 
 to the rectum. 
 
 BROAD LIGAMENTS. The broad ligaments, sometimes 
 called the pelvic diaphragm because they divide the pelvic cav- 
 ity into two parts and move synchronously with respiration, are 
 TWO LATERAL parts of the double peritoneal folds, which con- 
 tinue from the bladder over the uterus to be reflected on the 
 rectum, and CONTAIN within their folds the uterus and its append- 
 ages, the ovaries and their ligaments, Fallopian tubes, arteries, 
 veins, lymphatics and nerves supplying the uterus, the paro- 
 varium and the round ligaments. 
 
 They RESEMBLE, in shape, the outstretched wings of a bat 
 and are attached to the edge of the UTERUS and to the PELVIC 
 WALL. Their attachment to the pelvic wall corresponds to "a 
 line extending from a point midway between the sacro-iliac artic- 
 ulation and the ilio-pectineal eminence, downward and back- 
 ward between the great sacro-sciatic notch and the obturator 
 foramen to the level of the spine of the ischium." Thus a partial 
 dislocation of the innominate bones will, in some way, affect this 
 end of the broad ligament. The upper surfaces are free, while
 
 ANATOMY. 
 
 47 
 
 the other parts are attached to adjacent structures and vis- 
 cera and are continuous with the pelvic peritoneum. 
 
 They are not formed entirely of peritoneum but are LINED 
 throughout their whole extent with a layer of muscle fibers. Their 
 FUNCTION is to prevent lateral displacements, or in fact, any 
 other displacement resulting from a change of posture of the 
 body. When they are severed in the dead body, the uterus, 
 obeying the laws of gravity, inclines to the side on which the bod ' 
 is lying, while it reassumes its position when the ligaments are 
 sutured. 
 
 FIG. 26 View of pelvic organs seen from above (Savage). \\. Rectum, 
 O. Ovary. F. Fallopian tube, F. Fimbriae, L. Round ligament, U. Uterus, 
 B. Bladder, V. Vertebra, M. Pubic fat, b. Broad ligament, g. Ureter. 
 
 Between these two layers is located a pampiniform plexus 
 of veins which drains the ovaries and uterus. From the fact 
 that the broad ligaments are attached to the edges of the uterus 
 any forward or backward displacement will necessarily twist 
 these ligaments and compression of the vessels in the broad lig-
 
 48 DISEASES OF WOMEN. 
 
 aments varying with the amount of displacement, results. Press- 
 ure on the veins forming the above mentioned plexus, produces 
 a condition analogous to varicocele in the male. This condi- 
 tion is hard to diagnose during life, but a thickened, lumpy, 
 tortuous condition of the broad ligaments is symptomatic of this 
 disease, especially if there is a dull, constant ache in the re- 
 gion of this plexus. This congested condition also follows or 
 accompanies UNGRATIFIED SEXUAL desire, and is most to blame 
 for the heavy dead ache ivnariably referred to the ovary, in such 
 cases. As a result of this varicose condition , the ovary atrophies 
 or degenerates ; the FIBRO-CYSTIC form of degeneration being most 
 common. 
 
 In CONGESTION of the uterus following displacement, the 
 uterus, if possible, should be held in normal position for a few 
 minutes in order that these ligaments may become untwisted and 
 the engorgement of the blood be relieved. This can be done 
 digitally or better by the "Old Doctor's" UTERINE REPOSITOR. 
 
 Inflammation of these ligaments results in ovarian or Fal- 
 lopian tube disease, and in lateral displacement of the uterus, 
 as a result of their shortening, which is the usual effect of in- 
 flammation. A great many reflex troubles depending upon 
 uterine disease, result from a twisting or straining of these lig- 
 aments, that is, the DISPLACEMENT in itself DOES NOT CAUSE VERY 
 
 MUCH TROUBLE UNLESS IT AFFECTS THE NERVES and BLOOD VES- 
 SELS which are enclosed between the two layers of these ligaments. 
 A great deal of the tenderness of the abdomen which accompanies 
 uterine disease, is due to a THICKENING AND CONGESTION of these 
 ligaments, and by replacing the uterus the soreness will usually 
 disappear within a short time. In congestion or inflammation 
 of these ligaments the patient complains of a drawing sensation 
 in the side. On palpation in such conditions the ligaments can
 
 ANATOMY. 49 
 
 easily be palpated. I make it a routine practice to closely ex- 
 amine these ligaments when uterine trouble exists, since the 
 cause or effect is commonly found in them. In many cases this 
 TIGHTENING or DRAWING SENSATION is entirely due to a CON- 
 TRACTION of this ligament; which condition follows strains, mus- 
 cular, bony and visceral lesions. Reaching up, as in overhead 
 work, is responsible for many cases. 
 
 ROUND LIGAMENTS. The round ligaments, two in num- 
 ber, are attached to the upper corners of the uterus just in 
 front of and below the entrance of the Fallopian tubes, and ter- 
 minate in the mons Veneris, symphisis pubis, and labia majora. 
 Their course, describing a curve, is first upward and outward, 
 then downward and forward outside the bladder to the internal 
 abdominal ring and then through the inguinal canal, over the 
 pubic bone, at which place they terminate in the above men- 
 tioned structures. They are COMPOSED of FIBROUS tissue and 
 MUSCLE FIBERS which are CONTINUOUS WITH THE MUSCLE FIBERS 
 OF THE UTERUS, AND ARE CONTRACTILE. They receive addi- 
 tional muscle fibers, while in the inguinal canal, which muscle 
 fibers correspond to the cremaster muscle in the male. These 
 ligaments give off muscular branches which strengthen the EX- 
 TERNAL ABDOMINAL ring. 
 
 An artery, the funicular, a branch of the superior vesical, 
 a plexus of veins and the genital branch of the genito-crural 
 nerve, are contained in, or accompany the ligament. 
 
 In diseased conditions of the uterus which cause a weaken- 
 ing of its walls, the effect extends to the round ligaments, causing 
 their relaxation. During fetal life the peritoneum accompanies 
 the round ligaments, forming a pouch called the canal of Nuck, 
 which corresponds to the processus vaginalis of the male, but 
 usually becomes obliterated at birth. Sometimes it is persist- 
 
 4
 
 50 
 
 DISEASES OF WOMEN. 
 
 ent, and congenital female hydrocele results. During pregnancy 
 the round ligaments become very large and vascular. The 
 stretching of these ligaments during pregnancy, as a result of 
 the enlargement and ascent of the gravid uterus, is productive 
 
 (Round 
 Lig. 
 
 FIG. 27. The pelvic viscera of a woman Keen from above, (the left 
 ovary and tube have been drawn up into the left iliac fossa) (Testut) 
 
 of more or less pain or discomfort in the iliac fossae. Their 
 FUNCTION is to hold the uterus in ANTEVERSION and prevent retro- 
 displacements resulting from coughing or straining at stool. In
 
 ANATOMY. 
 
 51 
 
 cases of weakness of the uterus, these ligaments lose their tone 
 and the tendency to retro-displacement increases upon any in- 
 crease of intra-abdominal pressure. This function is ARTIFICI- 
 ALLY restored, or at least is supposed to be restored, by ALEX- 
 ANDER'S OPERATION, which consists of a shortening of the round 
 ligaments. HERNIA has followed this operation as a result of 
 the weakening of the abdominal wall at the point of exit of the 
 ligament at which place the incision is made. 
 
 FALLOPIAN TUBES. The Fallopian tubes, named after 
 their discoverer Fallopius, are two tubes about the size of slate 
 pencils, which connect the ovaries with the uterus. They are 
 from three to five inches in length. The tubes have their origin 
 in each corner of the Uterus, going first outward, then turn back- 
 ward, finally curving round the free end of the ovaries, some- 
 
 Fimbriated 
 extremity. 
 
 V 
 
 abdcuinale. \\b-^- 
 ,.Qy-<^ 
 
 KIG 28. Tlie Fallopian tube nml ovary 8*-en from behind. (Henle) 
 
 times entirely surrounding them. They have three coats; ser- 
 ous, muscular and mucous. Upon the mucous coat is found 
 ciliated epithelium which helps to convey the ova to the uterus.
 
 52 DISEASES OF WOMEN. 
 
 The tubes are divided into three parts; the isthmus, ampulla 
 and fimbriae. The ISTHMUS, or part attached to the uterus, is 
 the smallest part; the opening of the ostium internum is so fine 
 that it barely admits a bristle. The AMPULLA is the middle part 
 and is called the receptacle of the semen, because impregnation 
 is supposed to take place at this point. The ovarian end of the 
 tube, at which end is found the ostium abdominale, is surrounded 
 by fimbriae, they giving it the appearance of having tentacles. 
 One of these called the FIMBRIA OVARIANA, anchors the tube to 
 the ovary and facilitates the passage of the ovum to the tube. 
 Some authors say that these fimbriae are erectile, and, during 
 the escape of the ovum, surround the ovary. The function of 
 the tube is to transmit the ova to the uterus and to serve as a 
 receptacle for the spermatozoa. The ova arc transmitted by 
 suction, the action of the ciliated epithelium and by peristalsis. 
 The TIME required for an ovum to reach the uterus has been es- 
 timated to be from five to ten days. I have had patients tell 
 me that they could tell when the ovum was expelled; it usually 
 being about two days after the cessation of the menstrual flow. 
 From a few experiments, I have found that in some cases, a small 
 gelatinous mass is expelled within three days after menstruation, 
 this being the ovum and its attachments, and that impregnation 
 does not occur after its expulsion. 
 
 In diseased conditions of the tubes, its function is disturbed, 
 that is, the ova are not transmitted to the uterus, or at least very 
 slowly if at all, hence sterility or tubal pregnancy. Probably 
 a great number of ova fall into the abdominal cavity and there 
 dry up; although in some instances a spermatozoon finds its 
 way there, it being self-mobile, and abdominal pregnancy is the 
 result. 
 
 Fluids, when forced into the uterine cavity ,find their way
 
 ANATOMY. 53 
 
 into the abdominal cavjty by way of the tubes. This is especi- 
 ally true if intra-uterine douches are used in post-partum cases. 
 It is also the case in some instances in which the tubes are en- 
 larged. Cases of peritonitis are on record which followed an in- 
 jection of bi-cloride of mercury solution into the uterine cavity; 
 some of the fluid passing into the abdominal cavity by way of 
 the tubes and being absorbed by the peritoneum, produced a 
 poisoning. 
 
 In CONGESTION of the tubes, they can be outlined by ex- 
 ternal palpation. They are felt as tender, cord like bodies ex- 
 tending outward from the edges of the uterus. 
 
 THE OVARIES. The ovaries are two almond shaped bodies 
 
 FIG. 29. Ovary at the age of twenty. (From Schultze) 
 
 varying in size in different people and at different times in the 
 same individual, which are attached to the posterior layer of
 
 54 DISEASES OF WOMEN. 
 
 the broad ligaments, uterus and pelvic wall. They are about one 
 and one-half inches long, about three quarters of an inch wide, 
 and one-half an inch thick; and are located within an inch to an 
 inch and a half of the uterus. They are so near, and so securely 
 attached to the uterus, THAT EVERY UTERINE DISPLACEMENT 
 
 WOULD PRODUCE AN OVARIAN DISPLACEMENT. 
 
 The OVARIES are regarded as the MOST IMPORTANT of all the 
 pelvic viscera. Without them there would be no menstruation, 
 poor development of the uterus and the mammary glands, and 
 in fact, the other pelvic organs would practically be useless. 
 
 They are held in position by the broad, the infundibulo- 
 pelvic ligaments, which attach them to the pelvic walls, and the 
 ovarian ligaments, which anchor them to the uterus. Although 
 apparently securely attached, their mobility is quite marked, 
 and DISPLACEMENT is one of the most frequent of its lesions. 
 
 The INFUNDIBULO-PELVIC LIGAMENT is that part of the upper 
 margin of the broad ligament in relation with the Fallopian tube. 
 The OVARIAN, is a longitudinal fold of the peritoneum into which 
 unstriped muscle fibers from the uterus are prolonged. 
 
 During early fetal life they are found in the abdominal cav- 
 ity. DESCENT is not complete until about the tenth year. They 
 remain QUITE SMALL and undeveloped up to PUBERTY, at WHICH 
 
 TIME THEY ASSUME THE APPEARANCE OF AN ADULT OVARY. 
 
 The EXTERNAL LANDMARKS are the anterior superior spines 
 of the iliac bones; the ovaries being located about two inches 
 internal and one and one-half inches inferior to this spine. The 
 SIZE varies according to the age of the individual, and according 
 to the state of sexual activity. After cessation of sexual life 
 the ovaries atrophy, diminishing in size from one-half to one- 
 third. In old women they are often as small as peas, the atrophy 
 being gradual after the menopause. During pregnancy, how-
 
 ANATOMY. 
 
 55 
 
 ever, they are doubled in size. 
 
 They consist of two parts, the STROMA or framework and the 
 PARENCHYMA. They are covered by columnar epithelium, some- 
 times called germinal epithelium. Immediately beneath this 
 
 FIG. 30. Ovary at the age of forty. (From Schultze) 
 
 epithelial layer, is the tunica albuginea which is composed of 
 fibrous tissue which contains a few muscle fibers. 
 
 The Graafian follicles, in all stages of development, are em- 
 bedded in the connective tissue or stroma and contain the ova. 
 The younger and smaller lie in the cortical area. Their number 
 is immense, it being estimated from 40,000 to 70,000. During 
 menstruation one or more of these follicles ruptures, permitting 
 the ovum to escape. After rupture it is caught by the fimbriated 
 extremity of the tube, carried into the tube and transmitted to 
 the uterus, partly by action of the ciliae and partly by peristalsis. 
 
 In young women the ovary is smooth and glistening in ap- 
 pearance; but as the woman continues to menstruate, and the 
 Graafian follicles rupture,it begins to look scarred and corrugated; 
 in the aged its surface resembles the convolutions of the brain. 
 
 In diseased conditions, such as inflammation and conges-
 
 56 DISEASES OF WOMEN. 
 
 tion of the ovary, there is some interference with the rupture of 
 the Graafian follicle, and the ovarian form of dysmenorrhea re- 
 sults. This form is best diagnosed by the time of the pain in 
 reference to the beginning of the flow; it preceding the flow from 
 four to six days. As soon as this follicle ruptures, it is filled with 
 a yellowish fluid which is gradually absorbed, resulting in a scar, 
 which is called a CORPUS LUTEUM. If impregnation does not 
 follow the rupture of the follicle, it is called a FALSE CORPUS 
 LUTEUM, but if impregnation does take place, it is called a TRUE 
 corpus luteum and is not readily obliterated. 
 
 The ovary is a very common seat of disease and a favorite 
 organ for operations. The function of the ovary is to mature 
 and expel the 0va, and regulate menstruation, therefore any 
 diseased condition affecting this function will result in sterility 
 or menstrual disturbances, especially amenorrhea. 
 
 Williams speaks of an internal secretion of the ovary, that 
 has something to do with the elaboration of the blood. The 
 testes have an internal secretion, and it is generally believed the 
 ovaries likewise elaborate a somewhat analogous product, which 
 plays an important part in the female economy. Such a thing 
 is possible since atrophy of the rest of the genitalia follows so rap- 
 idly after removal of the ovaries, also the general effect is quite 
 marked; a WEAKENING or LESSENING OF PHYSICAL ENDURANCE 
 being most common. These things argue against removal 01 
 the ovaries "for trivial diseases. The true osteopath attempts 
 to save them before advising their removal. 
 
 The BLOOD SUPPLY comes from branches of the ovarian 
 artery, some six or eight in number, which enter the ovary at 
 the hilum; the VEINS follow the arteries and enter the pampin- 
 iform plexus in the broad ligament, from which the blood is 
 carried by the ovarian veins to the renal on the left side, and in-
 
 ANATOMY. 
 
 57 
 
 ferior vena cava on the right. On account of the presence of 
 the rectum on the left side and the left ovarian vein entering the 
 renal at right angles, and also the left vein having no valve, 
 
 THE LEFT OVARY IS MORE COMMONLY DISEASED THAN THE RIGHT. 
 
 FIG. 31. Lymphatics of vagina and uterus. 
 
 The lymphatic vessels empty into the lumbar glands. The 
 nerve supply comes from the INFERIOR HYPOGASTRIC plexus, 
 by way of the uterine and the OVARIAN PLEXUS, the latter of 
 which receives branches from the renal and aortic plexuses. The 
 lierves supplying the iliac fossae, the TENTH and ELEVENTH in- 
 tercostal, connect with the above plexuses; in fact, the source 
 of nearly all the nerve force for all the above named nerves and 
 plexuses is the TENTH AND ELEVENTH SEGMENTS OF THE THORACIC 
 SPINAL CORD. In most all ovarian affections, especially conges- 
 tion and inflammation, the pain is felt in the abdominal wall in 
 the area corresponding to the distribution of the tenth and 
 eleventh intercostal nerves, which is that part of the iliac fossa on a
 
 58 DISEASES OF WOMEN. 
 
 level with the anterior superior spines of the ilium. This explains 
 how vertebral lesions in the lower thoracic area affect the ovaries, 
 or in other cases, produce pains similar to those that accompany 
 ovarian diseases and which are often mistaken for such diseased 
 conditions. The PERITONEUM in relation is supplied by the above 
 mentioned nerves. In ovaritis nearly, if not all, the pain is in 
 the parietal layer of the peritoneum which forms a part of the 
 abdominal wall. 
 
 Byford mentions that a part of the nerve supply to the ovary, 
 connects with, or is derived from, the superior mesenteric plexus. 
 This plexus supples in the main, all of the small intestines, hence 
 the cramping in ovarian colic is often referred to the "stomach." 
 Perhaps the pain is really there, but in most cases the chances 
 are it is a "referred" pain. Fig. 26 illustrates the pelvic organs, 
 in situ, as seen from above. 
 
 THE PABOVARIUM. Connected with the ovary is a tri- 
 angular group of small tubules known as the parovarium, which 
 is the remnant of the Wolffian body. It is rudimentary and has 
 no function. It is of interest to gynecologists in that it is the 
 seat of various growths, especially of the CYSTIC VARIETY. 
 
 THE FEMALE URETHRA. The female urethra is a mem- 
 branous canal from one to one and one-half inches long, which 
 forms an outlet to the bladder. It has three coats; an outer or 
 connective tissue, a middle or muscular and an inner or mucous 
 coat. Vascular PAPILLAE are found in the mucous membrane, 
 and mucous glands are quite numerous. 
 
 In nullipara, the long axis is straight, while in multiparous 
 women it is slightly concave with its concavity upward and back- 
 ward, when the patient is in the dorsal position. This curve is 
 increased in cystocele and frequently to such an extent that a 
 sound or bougie has to be used to straighten the urethra, if
 
 ANATOMY. 59 
 
 there is much retention of urine or if micturition is otherwise in- 
 terfered with. The URETHRA is VERY DISTENSIBLE which is due 
 to the thinness of its walls, they being one-third thinner than the 
 walls of the male urethra. 
 
 The external opening is called the meatus urinarius, which 
 is in about the center of the vestibule. It presents a puckered 
 appearance and in multipara , the mucous membrane is often 
 found to be everted and protruding at the meatus. This is the 
 result of subinvolution of the anterior vaginal wall and of the 
 urethra itself. This is surrounded with various glands of which 
 SKENE'S GLAND is the most important. Sometimes it is the seat 
 of a vascular tumor called a caruncle, which is very painful. 
 
 In the introduction of the catheter if your are certain the 
 parts are clean, inspection is not necessary, otherwise it is. This 
 is a comparatively easy operation, the calibre of the female ureth- 
 ra being much larger and the canal shorter than in the male. 
 It is smallest at the meatus. 
 
 It is the seat of various inflammatory conditions, both simple 
 and specific, which give rise to pain, frequent micturition and 
 vulvitis. One writer takes the position that the urethra plays 
 the chief part in orgasm. He says, "whether in the male or 
 female the urethra is the part in which the orgasm occurs; in 
 the male by the passing of jets of semen over the mucous mem- 
 brane of the urethral canal; in the female by jets of mucus from 
 the neck of the bladder through the urethra. This explains the 
 habit in some individuals of passing all manner of objects into 
 the urethra and even masturbating in that way." Since the 
 nerve supply of the meatus is from the pudic , the above state- 
 ments are made quite probable. 
 
 THE BLADDER. The bladder is a hollow muscular organ, 
 located behind the symphysis pubis and supported, almost en-
 
 60 DISEASES OF WOMEN. 
 
 tirely, by the ANTERIOR VAGINAL wall, and which acts as a re- 
 ceptacle for the urine. The symphysis pubis is in relation in 
 front; the anterior surface of the uterus posteriorly and superi- 
 orly, and upper surface of the vagina inferiorly. It has the usual 
 THREE COATS, peritoneal, muscular and mucous. The muscular 
 coat at the neck is so arranged that it forms a loose sphincter; 
 SPHINCTER VESICAE. The base is not separated by peritoneum 
 from the uterus and vagina but is in direct contact, hence the 
 explanation of the frequency of fistulous openings between blad- 
 der and vagina or uterus. The female bladder differs slightly 
 in shape, from that of the male, the antero-posterior diameter 
 being shorter and the transverse longer. The CAPACITY of the 
 female bladder is greater than that of the male. 
 
 It has three openings, two for the entrance of the ureters 
 and one for the urethra. At the triangle, formed by the entrance 
 of the two ureters, is located the trigone, which is the most sen- 
 sitive part of the bladder. The uterus partly rests upon the 
 bladder and is changed in position by distention or collapse of that 
 organ. At the upper extremity is attached the urachus or lig- 
 ament of the bladder, which is a remnant of fetal life. Some- 
 times the urachus does not close and the urine in such cases 
 escapes at the umbilicus. 
 
 The MICTURITION CENTER located in the second lumbar seg- 
 ment of the spinal cord controls the action of the bladder. If an 
 unnatural pressure is exerted on the bladder, an impulse is con- 
 veyed to the center and then transmitted back to the sphincter 
 muscle and by its relaxation coupled with contraction of the 
 bladdere, vacuation follows. On this account, ANTE-DEVIATIONS 
 of the uterus, by producing abnormal or unnatural pressure on 
 the bladder, produce FREQUENT MICTURITION. If the pressure 
 is constant, painful spasms of the bladder will immediately
 
 ANATOMY. 61 
 
 follow micturition, to which is applied the term tenesmus. This 
 is especially true if congestion or inflammation of either is pres- 
 ent, which makes the irritation worse. 
 
 The bladder is an AIR TIGHT CAVITY and should be kept as 
 such; and the practice of washing out the bladder in case of 
 cystitis is to be condemned in most cases, it being almost impossi- 
 ble to prevent the entrance of air during the operation. Even 
 though no air enters, it is injurious to the walls of the bladder. 
 In the introduction of a catheter, care should be exercised as to 
 the lubricant used, lest something be introduced that might form 
 a nucleus around which a concretion be produced. Glycerine 
 and vaseline mixed in equal parts or pure vaseline is regarded 
 as the best lubricant. 
 
 The ARTERIES supplying the bladder are the superior, middle, 
 and inferior vesical. The VEINS form plexuses communicating 
 with those of the uterus, rectum and vagina, and empty into the 
 internal iliac. The NERVES come from the hypogastric plexus 
 by way of uterine and vesical, and directly from the sacral nerves. 
 
 On account of similarity of blood and nerve supply between 
 the uterus and bladder, diseases of one affect the other. Lesions 
 producing disease of one often produce disturbances of the other. 
 Often the worst cases of bladder trouble are directly due to 
 uterine disease. 
 
 THE RECTUM. The lowest division of the large intestine 
 is called the RECTUM. Although the word rectum means straight, 
 we find on examination there are several curves which are to be 
 considered. It enters the pelvis just in front of the left sacro- 
 iliac articulation; it goes first downward, backward and inward, 
 in front of the third and fourth sacral vertebrae, to the median 
 line. After it has reached the median line, it turns forward and 
 passing between the sacro-uterine ligaments, it lies in contact
 
 O^ DISEASES OF WOMEN. 
 
 with the lower portion of the uterus and upper part of the 
 vagina. 
 
 The uterus in retro-deviation can be readily felt through 
 the anterior wall of the rectum. It is capable of a great deal of 
 distention, and sometimes an accummulation of feces might be 
 mistaken for a fibroid tumor if care is not used in the diagnosis. 
 
 The RECTUM is composed of THREE coats, peritoneal, mus- 
 cular and mucous. The muscle fibers are arranged into a long- 
 itudinal and circular layer. At the upper limit of the ampulla 
 or dilated portion, which is on a level with the attachment of 
 the vagina to the cervix, the circular fibers are best marked and 
 there form the internal sphincter ani muscle. In cases of con- 
 stipation due to atony of the rectal walls, and such cases are 
 common, the mucous membrane is found to be prolapsed with 
 transverse folds which entirely occlude the lumen. 
 
 The upper portion is covered with peritoneum; the middle, 
 in front only, by a fold which forms the pouch of Douglas, while 
 the lowest portion is entirely free from peritoneal attachments. 
 The muscles connected with the rectum are the two sphincters 
 and levator ani, the latter pulling the rectum and perineum for- 
 ward and upward. An interesting fact is that the bowel 
 develops FROM BELOW UPWARD, according to Dr. Still, meeting 
 the small intestine, which is developed in the reverse direction, 
 at the cecum. On this account the nerve supply comes from 
 the lower part of the spinal cord, and advantage should be taken 
 of this in the treatment of constipation. 
 
 Relations. The RECTUM lies between the two sacro-uterine 
 ligaments, (see Fig. 25) and is in contact with the left ureter and 
 left internal iliac artery, having the left ovary in front and lying 
 in relation with the pyriformis muscle and sacral plexus. In 
 front it is separated from the uterus by the pouch of Douglas
 
 ANATOMY. 
 
 63 
 
 and sometimes the small intestines. In distention of the rectum 
 produced by constipation, the uterus is forced forward and the 
 circulation in the bowel and uterus interfered with. Again, in 
 retro-deviations of the uterus, pressure is exerted upon the rec- 
 tum, which may cause constipation, and pain or numbness in 
 the limbs, this being on account of the pressure against the sacral 
 nerves. Hemorrhoids, both internal and external, may also re- 
 
 FIG. 32. The sympathetic nerve mpply to tlio pelvic vifl- 
 cern . 
 
 suit. On account of the presence of the rectum on the left side, 
 and especially if there is constipation, the left ovary is more 
 frequently affected than the right.
 
 64 DISEASES OF WOMEN. 
 
 The BLOOD supply is from the superior hemorrhoidal, from 
 the inferior mesenteric, the middle hemorrhoidal, from the in- 
 ternal iliac; and the inferior hemorrhoidal from the internal 
 pudic. The VEINS form a large plexus which accompanies the 
 arteries. A part of the blood returns by way of inferior and 
 middle hemorrhoidal to the internal iliac, and part by way of 
 the hemorrhoidal to the inferior mesenteric veins. The NERVES 
 are mostly from the sympathetic, but some come from the sacral 
 plexus. Quain says: "Experiments on animals have shown 
 that the longitudinal muscle fibers of the rectum are supplied 
 with motor nerves from the anterior roots of certain of the sacral 
 nerves, SECOND AND THIRD, which nerves also supply inhibitory 
 fibers to the circular coat; whereas, the fibers of the HYPOGASTRIC 
 PLEXUS which supply the circular muscular tissue with Kiotor 
 fibers, are derived from white rami-communicantes of the an- 
 terior roots of certain of the LUMBAR NERVES, which join the sym- 
 pathetic chain and lose their medullary sheath before passing 
 to their distribution in the muscular coat." 
 
 The rectum acts as a receptacle for the feces. Their pres- 
 ence STIMULATES THE SENSORY NERVES INNERVATING THE BOWEL, 
 
 which impulses thus set up, are carried to the defecation center 
 and this center in turn, sends an impulse back to the muscles 
 which control the act of defecation. Sometimes lesions exist 
 which tend to lessen the degree of irritability, hence there must 
 be a greater irritant in order that impulses may be originated 
 and in such cases, constipation results. Again, the sensory 
 nerves may be irritated, thus keeping the center in a state of activ- 
 ity, and from this follows diarrhea. 
 
 In practice, the close sympathy that exists between the 
 uterus and rectum is often overlooked. One organ reacts on 
 the other, and on this account VARIOUS RECTAL AFFECTIONS
 
 ANATOMY. 65 
 
 are the RESULT OF A DISEASED OR DISPLACED UTERUS, and the 
 treatment should be directed to it instead of the rectum. This 
 remark especially applies to the condition of hemorrhoids, which 
 we find very common in parous women. Pain low down in the 
 left iliac fossa, is often due to a displaced uterus pressing on the 
 rectum. This pain, which is quite constant, may be as low as 
 Poupart's ligament. Replacement of the uterus usually gives 
 immediate relief. 
 
 THE PELVIC PERITONEUM. The pelvic peritoneum is 
 a continuation of the abdominal peritoneum, which, like a cloth, 
 covers the superior portion of the pelvic organs, folds of which 
 drop down between the organs forming their ligaments. The 
 peritoneal sac is a LARGE SPACE in which is a small amount of 
 lymph distributed over the surface for the purpose of lubrica- 
 tion. The LYMPHATIC VESSELS collecting the lymph eventually 
 empty into the RECEPTACULUM CHYLI, hence obstruction of the 
 thoracic duct will cause an accumulation of lymph in the peri- 
 toneal cavity, which condition is called ascites. 
 
 Beginning in front, the peritoneum extends from the ab- 
 dominal wall to the top of the bladder, covering its posterior 
 wall down to the level of the internal os uteri, and forming the 
 vesico-uterine ligament. From the posterior surface of the bladder 
 it passes to the anterior wall of the uterus, covering the anterior 
 wall as far down as the internal os; it then covers the edges, 
 forming the broad ligaments, and posterior surface of the uterus, 
 going as low as the upper portion of the vagina, from which it 
 passes to the rectum, thereby enclosing a space called the POUCH 
 OF DOUGLAS; the LOWEST POINT of the peritoneum. This pouch 
 is partially filled with small intestines and contains the ovary 
 when prolapsed. The peritoneum covers the anterior portion 
 of the middle, third, and surrounds the entire upper portion of 
 the rectum.
 
 66 DISEASES OF WOMEN. 
 
 The peritoneum in the female is PERFORATED by the en- 
 trance of the Fallopian tubes and on account of this, infection 
 may be transmitted directly into the peritoneal cavity; also there 
 is a possibility, as mentioned before, of the injection of fluids 
 into the peritoneal cavity in intra-uterine douches, especially 
 when the tubes are diseased. The peritoneum has great ab- 
 sorptive qualities and in case of retention of menses, peritonitis 
 may result. The rapidity of absorption is partly explained by 
 the great number of lymphatic vessels, the extensive area of 
 membrane drained, and by the peristalsis of the bowels which 
 disseminates the toxic material. 
 
 The peritoneum is very sensitive and in peritonitis, the least 
 movement produces excruciating pain. The most sensitive por- 
 tion is that in relation with the small intestines. A sudden dis- 
 placement of the uterus usually sets up an acute attack of per- 
 itonitis. The author has treated a number of cases of fevers 
 which were due to a displacement of the uterus which was affect- 
 ing the peritoneum. 
 
 During pregnancy the peritoneum is hypertrophied and 
 stripped from off the bladder. It should undergo the process 
 of involution after labor similar to that of the pelvic viscera. 
 Often this does not occur, and thus it remains stretched and 
 as a result the UTERUS is TOO FREELY MOVABLE and can be pushed 
 from one side of the pelvic cavity to the other. On this account 
 the uterus will be found to be in a different position, nearly every 
 time it is examined, for quite awhile after delivery. 
 
 In inflamed conditions of the uterus the disease may ex- 
 tend to the neighboring peritoneum and there set up a condi- 
 tion of perimetritis or local peritonitis, this usually terminating 
 in adhesions. These adhesions are in the peritoneal cavity and 
 care should be taken in their treatment lest there be hemorrhage,
 
 ANATOMY. 
 
 67 
 
 fermentation of the blood and diffuse peritonitis. The function 
 of the peritoneum is to anchor or support, and to permit of free 
 motion of, the viscera surrounded by it. 
 
 THE PELVIC FLOOR. The PELVIC FLOOR, which is com- 
 
 FIG. 33. Pelvic floor showing opening* and direction of muscle fibers. 
 
 posed of muscles, fascia, fat and connective tissue, closes the 
 lower opening, of the true pelvis. It is usually divided into an 
 ANTERIOR, or pubic segment, and a POSTERIOR or sacral segment. 
 The ANTERIOR SEGMENT is triangular, being attached to the pel- 
 vic bones in front and includes the structures lying between the
 
 68 DISEASES OF WOMEN. 
 
 symphysis and the vaginal orifice. The urethra and anterior 
 vaginal walls with the intervening fibrous tissues, go to form the 
 larger part of this portion of the floor. 
 
 The sacral segment includes the structures between the 
 vaginal orifice and the posterior pelvic wall. Comprised in this 
 are: the perineal body, posterior vaginal wall, muscles and con- 
 nective tissue. Both segments taken together comprise the 
 perineum. The principal muscle is the LEVATOR ANI, attached 
 anteriorly to the symphysis pubis and posteriorly to the coccyx. 
 It is a swing-like muscle, which, uniting with its fellow of the 
 opposite side, forms the most important part of the pelvic floor. 
 It is called by some the pelvic diaphragm; by its contraction it 
 assists the forcing of the blood through the uterus, helps to expel 
 fecal matter and most inmportant of all, it is the PRINCIPAL 
 
 FORCE WHICH HOLDS THE POSTERIOR VAGINAL WALL AGAINST 
 
 the ANTERIOR; in short, it pulls the perineal body forward and 
 upward. 
 
 The other muscles of the pelvic floor are from without in- 
 ward; the transversus perinei, the ischio-cavernosus,the sphincter 
 ani, the sphincter vaginae, the coccygeus and the levator ani, the 
 last mentioned muscle being located deepest. Although these 
 various muscles have been dissected out, as separate muscles, yet 
 their function is practically the same, that is, they act together 
 in pulling the perineum forward and upward. 
 
 The PERINEAL BODY is composed of the tissues comprised 
 between the rectum and the posterior vaginal wall. In it are 
 inserted most of the muscles of the pelvic floor. Upon its in- 
 tegrity depends the apposition of the vaginal walls; and upon 
 this depends the position of the uterus, at least its height. In 
 parturition this body may be lacerated through ignorance or 
 carelessness, thus weakening the keystone of the pelvic floor
 
 ANATOMY. 69 
 
 I know of few instances in which the osteopath was guilty of per- 
 mitting laceration of this body deep enough to require stitches, 
 the prevention of laceration of the perineum being one of the 
 claims for the superiority of osteopathic obstetrics over all other 
 methods. The author, out of over three hundred cases, has not 
 had a case in which the laceration involved the muscle fibers to 
 such an extent that an operation was necessary and only in a 
 very small per cent, of cases was there any laceration at all. 
 
 The perineum includes all the structures between the coccyx, 
 tuber ischii and the pubes. Sometimes this is confused with the 
 perineal body, but is a broader term, and includes the perineal 
 body. The pelvic floor is the principal support of the uterus 
 and upon its INTEGRITY and TONICITY depends the position of 
 the uterus. There is a certain amount of physiological descent 
 of the pelvic floor under different conditions. In respiration 
 the floor alternately ascends and descends. In coughing, laugh- 
 ing or in any other condition involving an increase of intra-abdom- 
 inal pressure, it is forced downward. Deep breathing, if per- 
 formed regularly and evenly, strengthens it. 
 
 In weak people, that is, in a condition of general physical 
 weakness, the floor remains in a POSITION OF DESCENT. The 
 TONE of the floor depends, partly at least, on the general condi- 
 tion, and on this account there is a great deal of difference in 
 the tonicity of the pelvic floor in different people. For instance , 
 if I find the vagina large, a leucorrheal condition and the tissues 
 soft, I at once suspect a displacement of the uterus. If the pel- 
 vic floor is relaxed, the two walls of the vagina will not be held 
 in apposition and air will enter the vaginal canal, which de- 
 stroys the equilibrium of the intra-pelvic pressure. 
 
 The NERVE SUPPLY of the pelvic floor is derived principally 
 from the pudic. The third and fourth sacral nerves, anterior
 
 70 DISEASES OF WOMEN. 
 
 divisions, also send filaments to it. From the nature of the 
 nerve supply, especially when the most important function of 
 these nerves is remembered, a connection between sexual im- 
 potence, or other similar disorders, and the condition of the pel- 
 vic floor can readily be seen. Excessive venery produces a re- 
 laxation of pelvic floor. The converse is also true. A rigid 
 pelvic floor usually is indicative of an irritated condition of the 
 sexual apparatus. Hemorrhoids cause an increase in sexual 
 passion. The above is true of the male as well as of the female. 
 
 To STRENGTHEN the pelvic floor, restore the normal nerve 
 supply by correcting lesions, prohibiting excessive venery and 
 by exercising the muscles forming the floor. Knee parting against 
 resistance is very good to develop these muscles. This can best 
 be done in the sitting posture. The RESTRAINING bowel move- 
 ment is also very good. In this, the bowel is drawn upward, 
 and the muscles of pelvic floor contracted by will power. These, 
 like other muscles, strengthen from use, and if the above men- 
 tioned exercise is kept up, the pelvic floor can be materially 
 strengthened. Activity is NECESSARY for muscular develop- 
 ment. 
 
 THE PELVIC CONNECTIVE TISSUE. The PELVIC CON- 
 NECTIVE tissue surrounds the pelvic organs and fills in the spaces 
 between the muscles that are found in the pelvic cavity. Its 
 function is that of steadying the pelvic organs, which, at every 
 step, are moved. From its ELASTIC character, jar from sudden 
 movements of the body as in running, is broken. It also dis- 
 tributes the nerves and blood vessels. It permits of a great de- 
 gree of stretching, upward as in pregnancy, or downward as in 
 prolapse, without serious impairment of either vessels or nerves. 
 Inflammation of the uterus readily spreads to it, which sets up 
 a secondary inflammation called cellulitis or parametritis. Some-
 
 ANATOMY. 
 
 71 
 
 times it furnishes the location for a deep-seated abscess, which 
 is very obscure and hard to diagnose. I once saw a case of pel- 
 vic cellulitis which had been treated for some months for ma- 
 laria; there being rigors, fever and sweats. A diagnosis can be 
 made by locating the abscess by CAREFUL EXAMINATION. A 
 
 HURRIED EXAMINATION SO OFTEN LEADS TO MISTAKES IN DIAG- 
 NOSIS. 
 
 THE BONY PELVIS. The BONY PELVIS is formed by the 
 articulation of four bones, the two innominate, sacrum, and 
 
 FIG. 34. The bony pelvis with the ligaments attached. 
 
 coccyx, each of which, in turn, is composed of a number of seg- 
 ments that were united early in life. The parts of the innomi- 
 nate bone, the ilium, pubis and ischium unite quite early, the 
 segments of the sacrum unite next in order, while the segments 
 composing the coccyx remain movable until past middle life. 
 
 The space enclosed by these bones is called the pelvic cav- 
 ity and is divided into two parts, the true and false pelvic cav-
 
 72 DISEASES OF WOMEN. 
 
 ities, the partition between the two corresponding to a plane 
 passing through the sacral promontory and the upper part of 
 the symphysis pubis. 
 
 The true pelvic cavity, roughly speaking, may be compared 
 to an obliquely truncated cone with its greatest height poster- 
 iorly, which measures a little more than four inches, while the 
 anterior portion measures less than two inches. With the woman 
 in an erect position, the upper portion faces forward and up- 
 ward and the lower portion faces downward and forward, which 
 facts indicate that the canal or tract is a curved one. 
 
 The walls of the true pelvic cavity are composed of bony 
 muscular, and ligamentous tissues. Posteriorly it is bounded 
 by the anterior surface of the sacrum; laterally by the ischial 
 bones and sacro-sciatic ligaments and muscles, while anteriorly 
 it is bounded by the ascending rami of the ischia, pubic bones, 
 and membrane covering the obturator foramina. This cavity 
 in the female contains some of the small intestines ; the bladder, 
 the uterus with its appendages, viz., the Fallopian tubes, ovaries 
 and their ligaments; blood vessels, lymphatics and nerves. Per- 
 itoneum or connective tissue surrounds each so that the cav- 
 ity is securely filled, there being not a portion but that is filled 
 in with tissue of some sort. 
 
 The false pelvic cavity is bounded below by the plane men- 
 tioned above as forming the superior boundary of the true pel- 
 vic cavity and comprises the space between the iliac bones. It 
 serves as a receptacle for the intestines. Sometimes the uterus 
 and bladder are forced up in this cavity; the uterus from en- 
 largement due to pregnancy, growths or congestion, the bladder 
 from pregnancy or overdistention. 
 
 The SACRAL PROMONTORY can readily be felt on abdominal 
 palpation except in the very obese. - In downward displace-
 
 ANATOMY. 73 
 
 ments, of the upper part of the sacrum, it is made more promi- 
 nent. Sometimes the uterus is incarcerated below the prom- 
 ontory and adheres to the sacrum. 
 
 The sacrum was formerly regarded as the "KEYSTONE" of 
 the pelvis but, as Matthew Duncan has shown, this is erroneous. 
 It represents an INVERTED KEYSTONE, since it is wider along its 
 anterior inferior surface than along its posterior superior sur- 
 face, so that it would tend to slip downward under the super- 
 imposed weight of the body were it not HELD IN POSITION by the 
 strong SACRO-ILIAC ligaments. 
 
 Certain imaginary PLANES are constructed through the pel- 
 vis for the purpose of locating or describing any given part. The 
 PLANE OF THE INLET passes through the sacral promontory and 
 symphysis, forming an angle of about 60 degrees with the hor- 
 izon when the patient is in an erect posture. Innominate lesions 
 alter this plane. A backward rotation of the ossa innominata 
 is the lesion most frequently found affecting this plane. The 
 plane of the outlet is determined by the tip of the coccyx and 
 the lower part of the symphysis. 
 
 The DIAMETERS of the pelvis vary in different individuals, 
 and in different races. The INTERNAL CONJUGATE diameter of 
 the inlet is approximately four and a half inches: the external 
 conjugate, seven and a half; the interspinal diameter, or dis- 
 tance between the two anterior superior spines, averages nine 
 inches. This diameter is the most variable of all, the degree 
 of flare of the iliac bones causing the variation. 
 
 The pelvic bones form FOUR JOINTS. The symphysis pubis 
 unites the bones anteriorly, and consists of fibre-cartilage, and 
 is made more secure by an anterior, a superior and an inferior 
 ligament. In the young, and during pregnancy, a variable 
 amount of MOTION EXISTS at this articulation. A SYNOVIAL
 
 74 DISEASES OF WOMEN. 
 
 membrane can be demonstrated in the above mentioned kinds 
 of cases. 
 
 The bones separate slightly during parturition, the degree 
 depending almost entirely on the age of the patient. On this 
 account the second stage of labor is easier in young primiparae 
 than in primiparae who are thirty or more years of age. The 
 other articulations are really of greater importance in parturi- 
 tion than the symphysis pubis. Dislocations occur oftener in 
 young primiparae than in other classes, on account of greater 
 mobility of this and the other pelvic joints. 
 
 The sacro-iliac articulation is usually described as a syn- 
 chondrosis, but I believe it belongs with the true joints, since a 
 synovia! membrane exists. These articulations have a greater 
 amount of motion than the symphysis. The degree of motion 
 depends upon the development of a synovial membrane, age of 
 patient and condition of the ilio-femoral and sacro-iliac ligaments. 
 In parturition , the sacrum is supposed to ROTATE SLIGHTLY. 
 Although this movement is slight, labor is made quite consider- 
 ably easier by it. Any lesion of either the sacrum or innomi- 
 nata will affect this articulation. Although it is quite a secure 
 joint and well protected by muscles and ligaments, lesions 
 occurring at labor or from other causes, especially trauma, are 
 quite common. 
 
 It is rare to find the two innominata the same height. In 
 right handed persons in whom the right half of the body is used 
 more than the left, the corresponding side of the pelvis is often 
 better developed than the other. Ordinarily this irregularity 
 has a PATHOLOGICAL SIGNIFICANCE, and points to a lesion at the 
 sacro-iliac articulation. Dressmakers often discover in cus- 
 tomers that one hip is higher than the other.' 
 
 The sacro-coccygeal articulation is much more freely mov-
 
 ANATOMY. 75 
 
 able than any of the other pelvic joints. It is subject to injury 
 from falls astride an object, from kicks, or blows directly on the 
 sacrum or coccyx. In forward rotation of the upper part of the 
 sacrum, this articulation is thrown into greater prominence on 
 account of the lower part of the sacrum being forced backward. 
 This carries the upper part of the coccyx back, but the muscles 
 and tissues attached to the tip DRAW IT FORWARD, or . at least 
 hold it in normal position. Often we blame the coccyx 
 for the disturbance when in reality, the sacrum is at fault. 
 
 Posteriorly the contour of the pelvis is determined by the 
 development of the glutei muscles. Generally speaking, the better 
 developed these muscles, the better developed the genital organs, 
 this not being true in obesity. The two sides of the buttocks 
 should be carefully compared. Often one is larger than the 
 other, indicating sciatica or an innominate lesion.
 
 76 DISEASES OF WOMEN. 
 
 GENERAL CAUSES OF DISEASE. 
 
 THE CAUSES of female disease are divided into the PREDIS- 
 POSING and the EXCITING. The predisposing causes are usually 
 chronic, and include heredity, poor development, environment, 
 dress, habits and lesions, the last named being the most im- 
 portant from the osteopathic standpoint. Education, or rather 
 the methods pursued in getting it, is an important factor in the 
 etiology of pelvic diseases. The worst feature is the length of 
 school hours, the competition, lack of exercise and position of 
 pupils while seated at their desks. The last mentioned cause is 
 very important and one that is overlooked, or at least minimized, 
 by the old school physicians. Usually the desk is too low and 
 the pupil bends, or rather humps, forward over her book, or in 
 the case of the younger pupils, it is too high. In writing, one 
 shoulder is elevated and the spine assumes an abnormal curve, 
 usually to the right and back, thus predisposing to a right scoliosis 
 and kyphosis. Thus this position repeatedly assumed, affects 
 the normal curve of the spine, which is usually soon replaced by 
 abnormal ones. In the lumbar region especially, the spine is 
 posterior. The pelvic viscera are necessarily weakened and as a 
 result, predisposed to disease. The explanation is, that the lumbar 
 spinal cord and its nerves control the pelvic viscera. 
 
 Potter, recognizing some of the defects in our educational 
 system, suggests: "For girls between twelve and sixteen, study 
 hours or school work be restricted to four hours daily; that dur- 
 ing each catamenial period, girls should indulge in much mental 
 and bodily repose; and that during the school period especially,
 
 GENERAL CAUSES OF DISEASE. 77 
 
 . 35. Girl writing at desk that is too high, showing effect on spine. (From photo)
 
 78 DISEASES OF WOMEN. 
 
 which is the period of most active growth, girls should be pro- 
 vided with an abundance of wholesome food. The dress should 
 be constructed with reference to relieving the waist line of all 
 weight and pressure." 
 
 The EXCITING CAUSES are many, such as exposure during 
 menstruation, falls, strains, overwork and emotional disturb- 
 ances. In most cases BOTH a predisposing and an exciting cause 
 are present. 
 
 HEREDITY. Heredity is usually named as a predisposing 
 cause of female disease. The defect existing in the mother may 
 be transmitted to a daughter, especially if there is a malforma- 
 tion or syphylitic disease. Again, if the mother is a sufferer 
 from a chronic uterine disease, the weakness or predisposition 
 to pelvic disease may be transmitted. I think this is the true 
 explanation of the part heredity plays in disease; that is, the 
 WEAKNESS, NOT THE DISEASE, is transmitted. On this account 
 it is sometimes well to get a history of the case and to ascertain 
 if a similar condition existed in the mother; if such is found the 
 prognosis is not so good. It must be also noted that children of 
 parents advanced in life at the time of their procreation are, as 
 a rule, less vigorous than those engendered in younger years. 
 Sexual intercourse indulged in to any great degree after quick- 
 ening, undoubtedly HAS AN EVIL INFLUENCE on the offspring. 
 Sexual perverts result. Nymphomania, or its opposite sexual 
 repugnance, is often developed in the offspring when the above 
 mentioned practices are persisted in. The thoughts and actions 
 of the pregnant mother influence the mental and physical develop- 
 ment of the fetus IN UTERO. Some authors state that actual 
 diseases in offspring follow MARITAL RELATIONS DURING PREG- 
 NANCY. The offspring of mothers who had exhausted all means 
 of preventing pregnancy, THE CHILD BEING AN UNWELCOME ONE,
 
 GENERAL CAUSES OF DISEASE. 79 
 
 early in life begin to show the prenatal influences that were brought 
 to bear. The child is cross, even vicious, this being the mental 
 effect, while in some, there is a physical effect in that the child 
 is marked or the pelvic organs are perverted or weak. 
 
 One important case which shows the physical effect of PRE- 
 NATAL INFLUENCE, occurs to me. The mother throughout term 
 complained of a severe backache in the lower dorsal region. The 
 child had such a weak spine that at the age of four years it was 
 unable to sit up, and died in a short time from malnutrition. On 
 examination of the child a lesion consisting of a separation, was 
 noticeable in the lower dorsal region. The pain left the mother im- 
 mediately on birth of the child. Possibly bony lesions were pres- 
 ent in both mother and child, the latter being injured at birth, 
 which is frequently the case, it then being only a coincidence. 
 
 The importance of PROPER CARE OF THE PREGNANT WOMAN 
 is not sufficiently emphasized, since the disposition, traits, in- 
 clinations, mentality, in fact the entire make-up of the child is 
 undoubtedly controlled, to a great degree, by prenatal influ- 
 ences of parents, especially the mother. 
 
 The PHYSICAL influences which are manifest by disease are 
 the ones which in reality, come in the scope of this work. Sexual 
 perverts, nymphomania, masturbation, ovarian and uterine 
 diseases usually classed as "female weakness" are the principal 
 effects on the girl when such diseases and conditions exist in the 
 mother during term. 
 
 Civilization has been given as an explanation for the pre- 
 valence of pelvic disorders. In the more highly civilized, the 
 mind, brain and nervous system are developed at the expense 
 of the other elements of her physical organism. Childbirth is 
 comparatively easy in the aboriginal woman because the pelvis 
 is large and the fetal head small. Although the above state-
 
 80 DISEASES OF WOMEN. 
 
 ments are generally admitted as being true, civilization should 
 not be accredited too much in the production of pelvic disease. 
 The most important point is that civilization tends to lessen physi- 
 cal development and increase the mental. If only a happy med- 
 ium could be struck, that is the physical be developed by work 
 or proper exercise along with the mind, civilization as a cause of 
 disease, would be eliminated. 
 
 ARREST OF DEVELOPMENT. Up to the time of puberty 
 the internal female organs are, or should be, QUIESCENT. At 
 the time of puberty there is a GREAT CHANGE AND INCREASE in 
 the nerve distribution to the pelvic organs. These organs BE- 
 COME VASCULAR and commence to perform their physiological 
 functions of ovulation and menstruation. Since the pelvic 
 organs develop at puberty and require at this time a large amount 
 of nerve force, this nervous energy should not be directed into 
 other channels, or there will be some interference with the de- 
 velopment of the genital organs. If, at this period, the YOUNG 
 GIRL'S NERVE FORCE, which is taxed to its limit in the full de- 
 velopment of her organs, is deflected by HARD STUDY OR WORK 
 TO OTHER ORGANS OR PARTS, disease will result. The sympa- 
 thetic or ganglionic nerves are the regulators of organic life, and 
 form the great channel for nerve distribution to the organs. 
 When in perfect action we have health; when impaired, disease; 
 and when their influence is entirely suspended, death fol'ows. 
 They carry nutrition, the smallest capillary being covered with 
 sympathetic filaments. If this nutrition is used to develop nerve 
 cells and muscle fibers instead of supplying the now developing 
 pelvic organs, NON-DEVELOPMENT, or other disturbances as 'stated 
 above, will ensue. 
 
 There are several conditions which are responsible for this 
 perverted condition of nutrition of the pelvic organs. The in-
 
 DISEASES OF WO.MEX. 81 
 
 tense rivalry amongst the young, (those who have reached the 
 age of puberty) and the competition which leads to over-study, 
 result in the building up of the brain at the expense of the physi- 
 cal; the genitalia on account of their change, being the important 
 parts to suffer. PHYSICAL OVER-WORK has a similar effect. Ac- 
 cidents, either from direct injury to the part or resulting in the 
 formation of spinal lesions, produce a perverted nutrition of the 
 ovaries and uterus, which amounts to an arrest of development. 
 This is especially true in cases of dysmenorrhea. 
 
 Many a woman DATES HER TROUBLE back to the commence- 
 ment of menstruation, and I find in getting a record of these 
 cases that overwork, either mental or physical, just before or at 
 puberty, is one of the important causes. 
 
 Too EARLY DEVELOPMENT might also be mentioned here. 
 This leads to menstrual disorders, principally MEXORRHAGIA. 
 It may also excite ovaritis as a result of the repeated conges- 
 tions of the ovary, which comes from too early development. 
 
 Reed mentions occupation as an important cause of female 
 weakness. He says: "The modern extension of woman's activ- 
 ity has brought with it more or less of a penalty in the form of 
 genital diseases induced by it. It was not to be expected that 
 women could adjust themselves without damage to labours 
 Avhich, through generations, had been arranged for men. Clerk- 
 ing in stores, with its long hours of uninterrupted standing, lift- 
 ing and carrying of heavy loads and the performance of over- 
 head tasks, which require stretching of the body, are the most 
 important examples which illustrate the influence of occupation 
 as a cause of female diseases." 
 
 CONSTIPATION. Constipation is a common cause or ac- 
 companiment of female disease; the vast majority of gynecol- 
 ogical patients suffering from it. On account of the proximity
 
 82 
 
 DISEASES OF WOMEN. 
 
 of the rectum to the uterus, an accumulation of feces gives rise 
 to local trouble, by pushing the uterus out of its place. Hab- 
 itual constipation causes OBSTRUCTION TO THE VENOUS CIRCU- 
 LATION of the pelvis and is a cause of congestive hypertrophy of 
 
 FIG. 3t> Impacted bowel forcing the utertiH Into slight retroversion. 
 
 the uterus, a VARICOSE CONDITION of the veins of the rectum and 
 even a stagnation of the blood in the VESSELS that lie between 
 the layers of the broad ligaments. The obstruction to the cir-
 
 GENERAL CAUSES OF DISEASE. 83 
 
 culation is at first purely a mechanical one, but at last the coats 
 of the vessels lose their tone, and, having become habitually 
 over-stretched, are very likely to remain in that distended con- 
 dition even after the pressure has been removed. 
 
 The absorption of the gases and liquid parts of the feces 
 affects the blood, and headaches, neuralgia and a general tired 
 feeling result. The straining at stool, which is a necessary ac- 
 companiment of constipation, tends to force the uterus and adnexa 
 downward in a state of prolapsus. In other cases, diarrhea compli- 
 cates menstruation; in some, taking the place of it. This shows 
 the close sympathy between the uterus and bowel; in fact, all 
 the pelvic viscera are, in a sense, mutually dependent. 
 
 DRESS. A girl scarcely enters her teens before fashion and 
 custom require a change in her mode of dress. Instead of her 
 clothes being supported by shoulder straps and buttons, the 
 skirts are held up by a number of strings and bands about the 
 waist. I have counted on patients, as many as ten different bands 
 encircling the waist. 
 
 By the wearing of CORSETS, the waist is drawn into a shape 
 little adapted to accommodate the organs of the abdominal and 
 pelvic cavities, and as the ABDOMINAL and SPINAL MUSCLES are 
 seldom brought into use, they BECOME ATROPHIED. The ab- 
 dominal viscera are compressed and displaced downward by the 
 tightly fitted corset, ~e action of the diaphragm interfered with, 
 and the VENOUS RETURN from the uterus to the heart hindered. 
 The uterus being very vascular, receives most of this blood thus 
 obstructed, with the result that its specific gravity is increased 
 and it is forced downward. 
 
 The wearing of small, TIGHT bands, belts or strings around 
 the waist is to be condemned as much as the wearing of a tightly 
 fitted corset. If such bands are necessarv, it is better to wear
 
 84 
 
 DISEASES OF WOMEN. 
 
 a loose corset which prevents them from sinking into the abdom- 
 inal wall, it being the lesser of the two evils. One writer says: 
 "In cases in which heavy skirts, the weight of which is supported 
 by bands, are worn, corsets should be worn. They should be 
 stiffer than usually made, if they are to effectively protect the 
 soft middle portion of the body from pressure of the waist band. 
 
 FIG. 37 Showing enteroptosis from 
 <in improperly worn corset. 
 
 FIG. 38 A properly fitted corset. 
 
 The front should be quite straight and the waist measurement 
 should be at least as large as the wearer's waist, measured over a 
 single garment." 
 
 The ribs are forced DOWNWARD until they, in some cases, 
 TOUCH THE CREST OF THE ILIUM. This forces the diaphragm
 
 GENERAL CAUSES OF DISEASE. 
 
 85 
 
 downward also, since it is attached to the lower ribs. The erec- 
 tor muscles of the back are weakened, on account of the body 
 being supported by artificial means. Degeneration and atrophy 
 
 of these spinal muscles follow 
 as a natural sequel, and the pa- 
 tient feels weak and exhausted 
 without her corset. 
 
 Deficiency of dress of the 
 neck, shoulders, arms and legs 
 is conducive to internal en- 
 gorgements, which are followed 
 by pathological congestion. 
 These are accompanied b y 
 leucorrhea, menstrual disorders, 
 local and reflex pains, and pos- 
 sibly uterine displacements from 
 increased weight. 
 
 How common a thing it is for 
 a young lady to attend some 
 function in the evening, dressed 
 
 . , i i-- , 
 
 m garments entirely different in 
 character and warmth from those 
 to which she has been accustomed. The most pernicious costume 
 is the decollete. INTERNAL CONGESTIONS particularly follow, 
 since the peripheral vessels contract from the effect of the 
 thermic influences. 
 
 If, at the age of puberty, while all articulations are subject 
 to change, high heeled shoes are worn, not only the shape of the 
 feet is altered, but the inclination of the pelvis is changed and 
 the normal curvature of the back deranged; a kyphosis of the 
 lumbar region resulting. The immediate effect is that of back- 
 cahe from the strain thrown on the spine. 
 
 FIG 39 Showing the injurious effect 
 
 of pressure on the uterus by corset 
 when the patient bends forward,
 
 86 DISEASES OF WOMEN. 
 
 STERILITY AND ABORTION. The function of the female 
 pelvic organs is that of PROCREATION and if this is interfered with 
 or not performed, it constitutes an unnatural state, thus form- 
 ing an important cause of female disease. Most forms of fibroid 
 tumors of the uterus are more common in the unmarried than in 
 those who have borne children, and still more common in the 
 sterile than in any other class. One explanation is that the 
 REPEATED MENSTRUAL CONGESTION and ovarian hyperemia 
 caused by sexual excitement, especially ungratified desires, cause 
 a deposit or produce an irritation from which the tumor forms. 
 In cases of dysmenorrhea, the physician frequently advises 
 marriage as a cure; this is in most cases a confession that he is 
 unable to cure the case. Marriage, when there is an existing 
 uterine disease, is usually contraindicated, it only aggravating 
 the disease, but in some cases of anteflexion or imperfect devel- 
 opment of the uterus, it is to be recommended. In many cases 
 the condition is made worse by marriage, if the laws of health 
 and nature are ruthlessly and repeatedly broken. 
 
 The practice of PREVENTING CONCEPTION is as old as his- 
 tory. Many methods are in vogue, such as the use of vaginal 
 douches, astringents applied to the mouth of the womb, the use 
 of a sponge to absorb the semen, womb caps, condoms and 
 other devices, all of which have a more or less DELETERIOUS effect 
 on the health of the individual. Although the local effect is not 
 at first very marked, the psychic, as well as the general effect, 
 becomes very great after a while. When practiced very long, 
 the patient becomes thin, nervous, has leucorrhea and feels "all 
 run down." This is in fact the condition. Progressive emacia- 
 tion is a common sequel. If pregnancy should accidentally take 
 place and the fetus is carried to term, the offspring are affected by 
 being handicapped by a weak constitution, a bad disposition
 
 GENERAL CAUSES OF DISEAE. 
 
 87 
 
 and possibly a perverted sexual organism. In a large per cent, 
 of cases, abortion, miscarriage or premature labor results. 
 
 Recently there was an editorial in one of the leading med^ 
 ical journals in which it was stated that "in the fashionable flats 
 (referring to New York City) A DOG is MORE WELCOME THAN A 
 BABY." This is undoubtedly true and depicts a deplorable state 
 of affairs. The nation's future is imperiled by such things. Even 
 now the bulk of the children are found in the poor man's home, 
 while those who are capable of properly rearing and educating 
 them, are childless. 
 
 Criminal abortion is one of the very important causes of 
 female diseases. Its prevalence is astonishing. Rigid laws have 
 been enacted against the practice, yet every city has its pro- 
 fessional abortionists, or its physicians, at least some one of 
 them, are in communication with such and get a per cent, of the 
 income from all patients sent. 
 
 The local effects are subin volution, displacement, leucor- 
 rhea, menstrual disorders, especially flooding and irregularity, 
 the various reflex aches and GENERAL DEBILITY. The after, and 
 general effects are NERVOUSNESS, aches of various kinds, and 
 mental depression. 
 
 LESIONS. From an osteopathic standpoint, the lesions 
 which are found along the spinal column and pelvic bones are 
 the most important of the predisposing, as well as exciting, causes 
 of female diseases. 
 
 By lesion is meant, if applied to a bone, a PARTIAL DISPLACE- 
 MENT OF THE BONE, ACCOMPANIED BY SOME DISTURBANCE SUCH 
 
 AS IRREGULARITY and TENDERNESS. Irregularity alone does not 
 constitute a lesion, but irregularity with tenderness or disturb- 
 ance of the function of the joint or viscus innervated by the 
 nerve in relation with the joint, constitutes a lesion.
 
 88 
 
 DISEASES OF WOMEN. 
 
 FIG. 40 Posterior curvature of lumbar region. (From photo of author's case.)
 
 GENERAL CAUSES OF DISEASE. 89 
 
 A lesion of the lower dorsal vertebrae (the 10th, llth and 
 12th) may cause pelvic disease by affecting the deep origin of 
 the pudic, sciatic, or in fact all the lumbar and the majority of 
 the sacral nerves. The segments of the cord from which the 
 pudic nerve arises, are on a level with the 12th dorsal and 1st 
 lumbar vertebrae. The spinal cord terminates at the upper 
 border of the second lumbar vertebra. The origin of all the 
 sacral and lumbar nerves must be above this point, thus a lesion 
 above this point, that is in the lower dorsal region, may affect 
 the nerves going to the uterus, ovaries, rectum, etc. Then arises 
 the question how a lesion, or what we call asubluxation of the 
 vertebra, or curvature would affect the deep or high origin of 
 these nerves. FIRST, the bone may cause a direct pressure on 
 the nerve trunk, but in such cases there is usually a complete 
 displacement of the vertebra coupled with paralysis, which con- 
 dition is rare compared with the partial displacements. A better 
 explanation is that the GANGLIA on the posterior nerve roots 
 which are in the foramina, are impinged upon, BY THE ARTICULAR 
 PKOCESSES, they being in direct relation. Also the BLOOD SUP- 
 PLY to the nerve cells is, in a like manner, affected, hence the 
 chronic disturbances, without complete paralysis, which would 
 follow continued pressure on a nerve. SECOND, it may affect 
 the NUTRITION of the cord or the blood supply to a segment of 
 the cord. The blood is returned by veins which empty into the 
 intercostal and lumbar veins, which also drain the muscles of 
 the back in that region. A subluxation of the vertebra, how- 
 ever slight, will affect the blood stream and a disturbance must 
 follow. A contracture of the back muscles, causes a stagnation 
 of the blood in the muscles and from this follows a venous conges- 
 tion of the corresponding part of the spinal cord. 
 
 The nerves usually affected are the pudic, sacral and the
 
 90 DISEASES OF WOMEN. 
 
 rami communicantes. In the case of the pudic nerve, a lesion 
 at the lower dorsal may cause inhibition or stimulation, that is 
 a loss of sexual vigor or increased passion, or nymphomania. 
 The pudic nerve innervates almost the entire pelvic floor. The 
 TONICITY of the floor to a great degree depends on the integrity 
 and healthy action of this nerve. The POSITION of the uterus 
 depends to a marked extent upon the amount of tone in the pel- 
 vic floor. From the above a conclusion can be drawn in refer- 
 ence to the relation of the pudic nerve to the pelvic floor and 
 uterine lesions. 
 
 An interference with the SACRAL nerves also causes a dis- 
 turbance of the pelvic floor, uterus and rectum, since the dis- 
 tribution of these nerves is to these parts. The KAMI COMMU- 
 NICANTES, are also impinged upon by a luxated vertebra, which 
 if in the lower thoracic region, produces a disturbance of the lesser 
 and least splanchnics. A disturbance of the least splanchnic 
 causes a change in the renal plexus. From this plexus is derived 
 the ovarian plexus, thus OVARIAN trouble and uterine disease 
 may follow as a result of such a lesion. 
 
 A subluxation of the llth or 12th rib, and by the way such 
 a lesion is common, may affect the gangliated cord, or as in the 
 case of vertebral lesions, the rami, which send branches to the 
 renal plexus from which is derived, in part, the ovarian plexus. 
 The gangliated cord is very near to, while the RAMI CROSS THE 
 
 HEADS Of THE RIBS, AND HOWEVER SLIGHT THE RIB LESION the 
 
 nerve will be affected thereby. 
 
 As to the way the nerves are affected, it depends on the dis- 
 placed bone whether it presses directly or indirectly on the nerves 
 or blood vessels. There may be paralysis, pain, or simply an 
 impairment of the function, The most common sequelae of these 
 lesions are, ovarian colic, inflammation, atrophy or enlarge-
 
 FIG. 41 Anterior curvature of thoracic region. (From plioto of author's case).
 
 92 DISEASES OF WOMEN. 
 
 ment of the ovary. These diseased conditions of the ovary re- 
 sult in painful menstruation, amenorrhea or menorrhagia. The 
 effect on the diaphragm and its relations to the pelvic organs 
 might be discussed, but I will only mention the fact that when 
 these ribs are displaced the position of the diaphragm is changed 
 and the return flow of blood affected. 
 
 A lesion of the LUMBAR VERTEBRAE may affect the GANGLIATED 
 cord which lies on the bodies of the vertebrae; it may affect the 
 RAMI COMMUNICANTES or the LUMBAR NERVES which go to make 
 up the lumbar plexus and the lumbo-sacral cord. The lumbar 
 gangliated cord sends branches to the AORTIC and INFERIOR 
 MESENTERIC plexuses, also to the inferior vena cava. The 
 ovarian, derived from the aortic, and renal, supplies the ovaries, 
 tubes and uterus. The inferior mesenteric, sends branches to 
 the left or descending colon, the sigmoid colon and the rectum, 
 on which account a lesion of the lumbar vertebrae may produce 
 ovarian, tubal , uterine or bowel trouble. It is a well known fact 
 that constipation often complicates uterine disease. One reason 
 is that the nerve supply is practically from the same source and 
 a lesion of the lumbar vertebrae will produce both. 
 
 Dr. Still once remarked to me that young girls in school, 
 in bending over desks and sitting in that position for several 
 hours every day, are often affected with a condition of kyphosis 
 which weakens the pelvic organs, bringing on backache, men- 
 strual irregularities fnd leucorrhea, since, from the changed re- 
 lation of the lumbar vertebrae, the above mentioned nerves are 
 affected. 
 
 The hypogastric plexus is located on the promontory of the 
 sacrum, hence a lesion of the 5th lumbar will usually affect this 
 plexus, and from this pelvic disorders arise. 
 
 The CENTERS FOR THE UTERUS, especially for the longitudinal
 
 GENERAL CAUSES OF DISEASE. 
 
 93 
 
 FIG. 42 Si might spine. (From photo of author's case).
 
 94 DISEASES OF WOMEN. 
 
 fibers, are located in the lumbar enlargement of the cord. These 
 centers may be affected by a lesion of the upper lumbar verte- 
 brae. The effect is usually one of weakening of the expulsive 
 forces of the uterus, hence menstrual disturbances, such as cramp- 
 ing, follow. 
 
 The above principle is exemplified in after-pains in labor 
 cases; they being due to insufficient contraction of the longi- 
 tudinal muscle fibers. 
 
 A lesion at the 1st and 2nd lumbar vertebrae might affect 
 the ILIO-INGUINAL arid GENITO-CRURAL nerves, since they make 
 their exit at the 1st and 2nd lumbar foramina. This would re- 
 sult in pain in the iliac fossae, loss of tone in the abdominal mus- 
 cles and round ligaments, as the ilio-inguinal and ilio-hypogas- 
 tric supply the abdominal wall, and the genito-crural the round 
 ligaments. From a weakening of these structures comes a weak- 
 ening of the supports of the uterus, and with this a tendency to 
 displacements, especially retro-deviation and prolapsus. 
 
 The lesions of the sacrum, while often overlooked and their 
 importance underestimated, are, notwithstanding, important 
 factors in connection with pelvic diseases. The sacrum supports 
 the weight of the body. Through it every jar is communicated 
 to the spinal column which is supported by it, and on account of 
 its position, being wedged in between the two innominate bones, 
 it is subject to a great deal of strain. On account of its obliquity 
 it is subject to DISPLACEMENTS of various degrees; the most com- 
 mon of these is a ROTATION, the upper part being thrown forward 
 and downward, the lower part backward and upward. 
 
 The STRUCTURES lying in relation with the sacrum are the 
 ROOTS OF THE SACRAL PLEXUS with most of its branches, the 
 hypogastric plexus with its immediate connection, and certain 
 ligaments, the most important of which are the utero-sacral
 
 GENERAL CAUSES OF DISEASE. 95 
 
 ligaments. These roots forming the sacral plexus, lie in rela- 
 tion with and are bound down to the sacro-iliac articulation, 
 hence the uterine diseases and the various disturbances of the 
 sciatic nerve which follow a twist or subluxation of either the 
 sacrum or innominate. 
 
 The UTERO-SACRAL LIGAMENTS have to do with holding the 
 lower part of the uterus in position, and are placed in an oblique 
 almost vertica 1 position, when the patient is erect. Disturbances 
 of the uterus as to its position follow, when these ligaments are 
 abnormally relaxed or put on a tension as they would necessarily 
 be in abnormal positions of the sacrum. 
 
 Of all the bony lesions associated with pelvic disease, a dis- 
 located INNOMINATE is the most common. Whether the case 
 bs one of menorrhagia or metritis, the innominates should be ex- 
 amined for some deviation from normal. This deviation is usually 
 a backward slip as is evidenced by irregularity and prominence of 
 the posterior spines of the ilium and tenderness at thesynchon- 
 drosis. The length of the limb is usually shortened if only a 
 rotation is present, but since some other displacement often 
 accompanies a rotation, the length of the limb is not a very 
 reliable indidation by which to diagnose the character of the 
 innominate lesion. However, the question before us is '' how does a 
 slipped innominate cause pelvic disease?" 
 
 The ROOTS OF THE SACRAL plexus, as stated before, are in 
 relation with and ARE BOUND TO THE ILIO-SACRAL ARTICULATION, 
 hence any deviation at this point, however slight, will affect 
 the sacral nerves. It is a well known fact that sciatica and 
 other limb troubles, are often associated with pelvic diseases. 
 This is explained by the above. The sacral nerves are especially 
 distributed to the cervix and are important factors in expulsion 
 of the contents of the uterus. By an IRRITATION of these nerves,
 
 96 DISEASES OF WOMEN. 
 
 the os is constricted and menstruation made painful. By an 
 INHIBITION, the os remains patulous and menorrhagia is often 
 found. THIS LESION OFTEN DESTROYS THE HARMONY EXISTING 
 
 BETWEEN THE CEREBRO-SPINAL AND SYMPATHETIC SYSTEMS. 
 
 Whether expulsion is interfered with by an obstruction, or by 
 an insufficient contraction of the longitudinal muscle fibers, 
 THE RHYTHM is DESTROYED and disturbance of function follows. 
 To me this is a very important point. Again, the intimate connec- 
 tion existing between the sacral plexus and the sympathetic gang- 
 Hated cord will also help in explaining the relation between the 
 cause and effect. The white rami, and some say the gray, con- 
 nect the roots of the sacral plexus with the sympathetic chain; 
 this chain also gives off branches which go direct to the inferior 
 hypogastric plexus, thus there is a direct connection be ween 
 the two. 
 
 By a subluxation of the innominate bone, certain muscles, 
 especially the iliacus and levator ani, would be put on a tension 
 or relaxed and, since they are in relation with the pelvic struc- 
 tures, derangements would follow. The broad ligaments are 
 attached to the sides of the innominate bones. On account of 
 their connection with the uterus and the relation to the vessels 
 and nerves which supply it, a twisting, increased tension or re- 
 laxation, will materially affect the amount of blood passing to 
 and from the uterus. The displacement of the innominate bones 
 will AFFECT ALL TISSUES attached to them; this will in turn affect 
 all neighboring structures and organs. On this account the 
 PUDIC NERVE is liable to be affected, at or near the place at which 
 it crosses the spine of the ischium. 
 
 A displacement of the coccyx often causes disease by putting 
 muscles on a strain, by affecting the GANGLION IMPAR, or by 
 pressure on neighboring structures or organs. Hemorrhoids
 
 GENERAL CAUSES OF DISEASE. 97 
 
 often result from a displaced coccyx. PRURITUS ANI or itching 
 piles are often found. In such cases there are often found sexual 
 derangements, the most common of which is a form of nympho- 
 mania. 
 
 OUR CONCLUSION is that very particular attention should 
 be paid the bony framework, since a derangement of it forms the 
 basis of nearly all female diseases, especially the chronic types. 
 One of the fundamental principles of osteopathy is based on the 
 condition of the framework of the human body, and constitutes 
 the point of greatest difference between it and the various pathies. 
 
 If any of these lesions mentioned are found in a case of in- 
 flammation of the uterus, all the topical applications known 
 will not cure, although they may temporarily relieve, until the 
 abnormality is corrected. The exciting causes of uterine dis- 
 eases act with difficulty if the bony framework is perfectly ad- 
 justed. The secretions will be normal, the circulation good, 
 the lymphatics will act properly and the position of the uterus 
 will not become pathological. The old dictum that the BLOOD 
 is THE LIFE is of more importance to the osteopath than to any 
 other class of practitioners. The blood is both food and air to 
 the tissues, and also acts as a scavenger. It carries nutrition and 
 takes away the deleterious products. The blood, to fulfil its 
 function or purpose, must be MOVING. It cannot CARRY nutri- 
 tion or TAKE AWAY deleterious products IF IT DOES NOT MOVE, 
 and that quite rapidly. 
 
 There are several factors or forces besides that of the heart 
 concerned in the propulsion of the blood through its circuit. 
 PRESSURE, exerted by contraction of organs or tissues, forces 
 the blood into the veins and the arterial blood rushes in to fill 
 the vessels thus emptied. The veins, having valves, allow the 
 blood to be forced in only one direction, that is toward the heart. 
 
 7
 
 98 DISEASES OF WOMEN. 
 
 THIS PRESSURE, to be effective, must be intermittent. Standing 
 on the feet, in which the pressure is constant, produces fatigue. 
 FATIGUE is DUE TO IMPOVERISHED BLOOD; impoverished blood is 
 due to a stoppage or LESSENING OF RAPIDITY OF BLOOD CURRENT 
 in SOME PART OF THE BODY. In ordinary fatigue from muscular 
 exercise, the STOPPAGE is IN THE VEINS OF THE MUSCLES. EK 
 ercise, if not excessively indulged in, by which the muscles con- 
 tract intermittently, is an aid to the circulation. 
 
 BONY LESIONS PRODUCE CONTRACTURE OR RELAXATION OF 
 MUSCLES. Either disturbs the function and destroys the inter- 
 mittent pressure which, as stated above, is of assistance in the 
 circulation of the blood. This furnishes another reason why 
 lesions produce disease. 
 
 It might be mentioned in this connection that respiration, 
 which is the result of a rhythmical contraction of the muscles con- 
 cerned in the respiratory function, exerts a wonderful influence 
 on the pelvic circulation. Deep rhythmical breathing tends to 
 force the blood more rapidly through the uterus than shallow, 
 irregular respiration. In fact, the latter results in uterine con- 
 gestion and is the cause in some cases, of the uterine disease. 
 In summing up the various causes of female disease we are forced 
 to the conclusion that a perfect CIRCULATION THROUGH THE PEL- 
 VIC VISCERA is NECESSARY to the perfect functioning of those 
 parts, and that ANY LESION OR OTHER PATHOLOGICAL CONDI- 
 TION interfering with this, PREDISPOSES TO DISEASE of the pelvic 
 viscera. If the BLOOD is PURE and CIRCULATES NORMALLY through 
 the uterus, there is little or no danger of it becoming diseased. 
 
 EXCITING CAUSES. Childbirth is one of the most important 
 of the exciting causes of disease, especially if laceration has 
 taken place and has not healed. Tears of the vagina or peri- 
 neum lay the foundation ! for prolapsus of both vagina and uterus.
 
 GENERAL CAUSES OF DISEASE 99 
 
 Laceration of the perineal body weakens the keystone of the 
 pelvic floor, impairing its function to such a degree that it is im- 
 possible for the two vaginal walls to be held in apposition. This 
 is made the more likely on account of the increased size of the 
 fetal head from civilization and education. 
 
 LACERATION of the CERVIX, which is usually the result of 
 administration of ergot or quinine causing too rapid delivery, 
 prevents proper involution after delivery. From this follows a 
 CONGESTIVE HYPERTROPHY accompanied by a hypersecretion or 
 leucorrhea, also displacements with their accompanying aches 
 and reflex pains. I am glad to say that the OSTEOPATH, IN OR- 
 DINARY CASES, PREVENTS THESE LACERATIONS FROM TAKING 
 
 place, thereby preventing an inestimable amount of disease. 
 Many cases of neurasthenia and hysteria result from a lacerated 
 cervix, which has not healed and keeps the parts irritated, causing 
 a constant loss of nerve force. 
 
 It is sufficient at present to call attention to the fact that 
 the cervix is covered with ERECTILE TISSUE and is therefore sup- 
 plied with a great many blood vessels, which are enclosed in a 
 network of nerves from the sympathetic system. 
 
 Too early rising after confinement, before the uterus has 
 contracted sufficiently often causes enlargement and displace- 
 ment of the organ. Again, if the patient remains in the dorsal 
 position too long after confinement, retro version will usually 
 result, all of which tend to increase the amount of blood in the 
 uterus. This in turn, affects the nerves in relation. 
 
 Labor predisposes to female disease, in that lesions, especi- 
 ally of the spine and pelvis often result from it. The position 
 of the patient, the fearful straining, especially in hard cases, ALL 
 TEND TO DISPLACE the vertebrae, innominata, hips, sacrum or 
 coccyx. This results in a weakening of the pelvic viscera, as
 
 100 DISEASES OF WOMEN. 
 
 previously noted. Such lesions, especially of the innominate 
 bones, occur quite easily on account of the increased mobility 
 of the sacro-iliac synchrondrosis during pregnancy, the patient 
 often complaining of a "catch" in the hip, sometimes severe 
 enough to cause her to fall. This is due to a slight slip in the 
 sacro-iliac joint. Milk leg is the occasional sequel of such a 
 lesion, and in many cases the hip is also involved. 
 
 A PENDULOUS ABDOMEN is a common sequel to labor and 
 predisposes to pelvic disease by producing ENTEROPTOSIS, which 
 condition interferes with the normal circulation through the 
 pelvic viscera. The intestines are forced into the pelvis and 
 congestion, with its so-called catarrh or leucorrhea is a common 
 effect. 
 
 Occasionally an OVARY is CAUGHT between the fetal head 
 and the brim of the pelvis and there bruised or lacerated. An 
 ovarian abscess often follows such an injury; at least ovaritis is 
 produced. 
 
 The proper care of labor cases will prevent a great many 
 female disorders. Prophylaxis is even of greater importance 
 than curative measures that are not applied until after the dis- 
 ease is under headway. 
 
 GYNECOLOGICAL TREATMENT. The practice of intro- 
 ducing an instrument into the uterine cavity to correct a dis- 
 placement is sometimes the cause of inflammatory conditions 
 of the uterus. The ENDOMETRIUM is a VERY DELICATE membrane 
 and although a dull sound is used, the chances are that this mem- 
 brane will be injured. The practice of curetting the uterus, as 
 is ordinarily performed by the regular physician, is to be more 
 severely condemned. Unless polypi or cancerous growths are 
 present, curetting is contraindicated, because it leaves a raw, 
 bleeding surface which results in inflammation or perhaps in-
 
 GENERAL CAUSES OF DISEASE. 101 
 
 fection and even in the above mentioned cases is rarely indicated. 
 
 All intra-uterine treatments with sounds, curettes, tents, 
 dilators and pessaries are fraught with danger on account of the 
 absorptive qualities of the uterine lymphatics. Nearly all intra- 
 vaginal treatments in which instruments are used, are injurious. 
 I have examined cases in which pessaries were found embedded 
 in the tissues of the vagina, having been there several months. 
 The practice of using pessaries irritates the mucous membrane 
 and keeps it inflamed, preventing nature from healing the part. 
 
 DOUCHES, if indulged in for any length of time, are the cause 
 of disease. The author has noted case after case in which 
 douches had been used and in every one, found the fornices dis- 
 tended, thus forming QUITE A CAVITY around the cervix. This 
 induces uterine displacement, particularly retro version and 
 prolapsus. CAUSTICS applied to the cervix in the treatment of 
 certain forms of disease are injurious and tend to prolong the 
 existing disease. ASTRINGENTS have also been advised but their 
 use is not indicated except in severe cases of metrorrhagia. Such 
 applications used for any length of time destroy the function of 
 the mucous glands lining the vagina. As a result the walls be- 
 come dry, and become covered with wrinkles or folds. A local 
 digital examination is hard to make in such cases and the sexual 
 function is impaired, or more often, destroyed. In other cases 
 the condition of the mucous membrane of the vagina is a very 
 reliable index to the condition of the sexual organs. FREQUENT 
 LOCAL TREATMENT as ordinarily practiced is an exciting cause of 
 disease. They should not be given more often than once a week, 
 except in very unusual cases. Often the nervous shock counter- 
 acts the good they do. 
 
 GONORRHEA. LATENT or chronic gonorrhea is a cause 
 of many of the various forms of uterine, tubal and ovarian dis
 
 102 DISEASES OF WOMEN. 
 
 ease, especially of the inflammatory and suppurative types. The 
 inflammation extends from the vagina through the uterus to the 
 Fallopian tubes, peritoneal cavity and ovaries. This result 8 
 in a chronic type of inflammation characterized by the formation 
 of adhesions. It manifests itself by a general weakness, back- 
 ache, leucorrhea, sterility, chronic soreness over the tubes and 
 ovaries, the result of the chronic inflammation, and by DISCHARGE 
 OF PUS in the more pronounced cases. Byron Robinson states 
 that "gonorrhea is the essential element in a vast majority of 
 intra-pelvic suppuration." This is true of most chronic dis- 
 charges. He also states that "the disease (referring to latent 
 gonorrhea) is incurable;" that the "acquired gonococcus is never 
 wholly eradicated from the pockets, recesses and folds of the 
 genito-urinary tract, that the gonorrheal germ simply repro- 
 duces itself in undisturbed locations." Perhaps the above is 
 an exaggeration, yet the frequency of such conditions is astonish- 
 ing. The author regards it of so much importance that a MICRO- 
 SCOPICAL EXAMINATION is advised in all cases of chronic discharge 
 from the genitalia, especially if the case does not readily respond 
 to the ordinary treatment. In some, the discharge is so strongly 
 acid that the gonococci are hard to recognize on account of dis- 
 integration. In such cases repeated examinations are necessary. 
 In doubtful cases an examination of the husband will clear up the 
 diagnosis. The indications of latent gonorrhea in the husband 
 are: an occasional mucous discharge, disturbances of micturi- 
 tion, prostatitis, tenderness along the posterior urethra and his- 
 tory of an attack of specific urethritis some years prior. If the 
 urethritis once passes beyond the triangular ligament into the 
 prostatic and membraneous portions of the urethra, a complete 
 cure is almost impossible and many a case of ovarian, tubal and 
 uterine disease is caused by such.
 
 GENERAL CAUSES OF DISEASE. 103" 
 
 EXPOSURE DURING MENSTRUATION is a very common, 
 exciting cause of uterine disease. This occurs very frequently^ 
 in society people, they refusing to give up the pleasure of the ball 
 room even for a few nights during the month. I have seen many 
 cases of menstrual disorders which could be traced back to- 
 dancing during the menstrual period; getting warm and cool- 
 ing off too suddenly. I have known of many cases in which the 
 patient sat in a cold class room when she was menstruating, and 
 as a result the flow stopped, inflammation of the uterus develop- 
 ed and the patient was confined to her bed for weeks. The ces- 
 sation of the flow from exposure is often the starting point of 
 various female disorders, such as vicarious menstruation, dys- 
 menorrhea, amenorrhea, flooding at the monthly periods, and 
 all forms of inflammatory disturbances of the pelvic peritoneum 
 and the internal generative organs, especially acute inflamma- 
 tion of the uterus. Special care then should be taken of one's 
 self at this time because exposure usually results in the stopping 
 of the flow, which is detrimental to the organism by causing, 
 not only local inflammations, but systemic diseases from reten- 
 tion of the discharge. 
 
 The old Mosaic law that a menstruating woman should be 
 put apart seven days, (that is, rest that length of time) is a good 
 one, and if it were followed a little more closely at the present 
 time, much suffering could be avoided since any exposure or 
 overwork at one period, causes a disturbance of the next. 
 
 TRAUMATISM. The osteopath traces a great many 
 troubles to falls, strains and injuries of the back. A FALL 
 BACKWARD, if the bladder is distended, usually results in a RE- 
 TRO-DISPLACEMENT of the uterus, especially if the ligaments are 
 weak. Unless this is corrected within a short time, the patient 
 becomes a chronic invalid, or at least has chronic uterine trouble.
 
 104 DISEASES OF WOMEN. 
 
 Lifting a heavy weight will often strain the lower part of the 
 back, which causes a subluxation of the vertebrae in relation, 
 thus impairing the nerve supply to and from the uterus. This, 
 like the above, usually causes uterine displacements by the sud- 
 den change or increase of intra-abdominal pressure. Reaching 
 upward, while in a strained position, or the carrying of platters, 
 as do waitresses in hotels, is a common exciting cause of female 
 disease; the ovaries and tubes being most frequently affected.
 
 METHOD OF EXAMINATION. 105 
 
 METHOD OF EXAMINATION. 
 
 SUBJECTIVE EXAMINATION. When a patient comes into 
 your private office for examination, there thould be some SYS- 
 TEM OR REGULARITY followed in the examination, otherwise 
 some important points may be overlooked. In the examina- 
 tion there should be REGARD for the PATIENT'S FEELINGS, and it 
 ought to be restricted to that which is absolutely necessary. 
 
 In the first place a number of points should be ascertained; 
 the AGE of the patient ; whether MARRIED or SINGLE; LENGTH of 
 standing of the disease; and if she has borne children, the charac- 
 ter of the LABOR, whether FORCEPS or other artificial means were 
 used. The next question amounts to this have you any PAIN 
 OR TENDERNESS of any part? Where do you ache? When is 
 the ACHE worst. Does standing on the feet make it worse? Under 
 what conditions is the ache worst? Sometimes it is well to ask 
 the patient WHAT THE MATTER is. If there is pain try to get her 
 to locate it for you; try to get some measure of its severity, when 
 it occurs and length of time it lasts. Try to ascertain the ONSET 
 of the pain or disease, whether it came on suddenly or gradu- 
 ally. Very frequently the patient will tell you that it commenced 
 when she lifted a tub of water or when reaching for some article 
 on a high shelf. Ask the patient if she sleeps well ; insomnia 
 being a common complication of uterine disease. Ask whether 
 or not she suffers from headaches and in WHAT PART OF THE HEAD 
 the pain is located; and whether or not she is more nervous than 
 she used to be. Ask as to the menses; the date of their com- 
 mencement, their regularity or irregularity, the quantity, if
 
 106 DISEASES OF WOMEN. 
 
 there is pain, and when the pain occurs in relation to the flow. 
 NORMAL MENSTRUATION is PRECEDED AND ACCOMPANIED ONLY 
 
 BY A FEELING OF WEIGHT IN BACK AND PELVIS. "MENSTRUAL 
 PAIN IS ALWAYS A SIGN OF DISEASE." If PAIN PRECEDES THE 
 
 FLOW it is probably ovarian in origin. If the flow relieves the 
 pain an OBSTRUCTION should be thought of; while in cases in 
 which pain continues after the flow starts, INFLAMMATION of the 
 endometrium is probably the condition. 
 
 If amenorrhea exists, ascertain when the menses ceased, 
 and the supposed cause. If molimina exist the amenorrhea is 
 pathological; if not, physiological. Pregnancy should be borne 
 in mind in all cases of amenorrhea. 
 
 Ask about MICTURITION, whether it is painful or too fre- 
 quent; whether or not there is a vaginal discharge. If there is, 
 ascertain if possible its CHARACTER. AMOUNT and LENGTH of 
 standing. ANY DISCHARGE is ABNORMAL. The thinner and 
 more glairy, the less important ; the thicker and more purulent 
 points to marked disease conditions. Inquire about the bowels, 
 whether there is pain in defecation; if there is constipation or 
 hemorrhoids. The OCCUPATION of the patient should be ascer- 
 tained since many forms of disease can be rightfully attributed, 
 directly or indirectly, to it. If a patient stands on the feet a 
 great deal, lifts heavy loads or does overhead work, displacements, 
 congestion, leucorrhea and tubal diseases are suggested. 
 
 The MARITAL and SEXUAL HISTORY is of importance in some 
 cases. In addition to inquiring about normal pregnancies, 
 character of labor, etc., ascertain if the patient has ever aborted, 
 the date, cause and result; whether or not diseased conditions, 
 such as metritis, followed. Sometimes it is important to know 
 whether intercourse is painful or distasteful to the patient. Per- 
 haps there is lack of orgasm, which is quite common; or there
 
 METHOD OF EXAMINATION. 
 
 107 
 
 Fi<;. 43. Lateral curvature of spine. (From photo of author's ease.)
 
 108 DISEASES OF WOMEN. 
 
 is a sexual perversion. The patient will usually drop a hint if 
 such conditions exist; if they do you can follow it up with lead- 
 ing questions. Although the osteopathic physician depends 
 very little on the subjective method of examination, it is prob- 
 ably a good plan to let the patients describe their own cases ; 
 which they usually do with a little assistance. 
 
 EXAMINATION OF THE ABDOMEN. In order to make 
 a satisfactory examination of the abdomen all clothing over 
 the part should be removed, the woman then placed in the 
 dorsal position. By INSPECTION the general size and contour of 
 the abdomen and the presence of dilated veins or lineae albi- 
 cantes can be ascertained. The LINE.E ALBICANTES indicate 
 that the patient's abdominal wall has been stretched beyond the 
 normal tension and are not diagnostic of a former pregnancy, 
 since they occur in tumors, ascites, etc. Fresh lines are glisten- 
 ing and pearly, old ones scarred and white. 
 
 The UMBILICUS should be concave with flattening of the ab- 
 domen around it. If the abdominal cavity is distended from 
 gas or ascites, the umbilicus becomes flattened or even slightly 
 bulged. The enlargement produced by fat is different from that 
 produced by ascites or fibroid tumors. Tumors or enlarged 
 organs produce a fullness which is most pronounced in the neigh- 
 borhood of their origin. Cause the patient to breathe deeply 
 and NOTE whether or not the TUMOR MOVES and whether or not 
 the SKIN BECOMES IRREGULAR. Move the patient into differ- 
 ent positions in order that it may be ascertained if tumor changes. 
 A change of contour takes place in ascites and in large cysts. 
 Examine for SCARS resulting from operations, since laparotomy 
 for various purposes, is such a common operation. Be on the 
 lookout for evidences of such an operation since the prognosis 
 may be materially changed by it.
 
 METHOD OF EXAMINATION. 109 
 
 Palpation of the abdomen is the most important form of 
 examination. At first the physician should secure the patient's 
 confidence and, after the hands are warmed, proceed with both 
 hands to gently and slowly externally palpate the abdominal 
 and pelvic organs. The patient being in the dorsal position, the 
 LIMBS SHOULD BE flexed on the abdomen in order to relax the 
 abdominal muscles. At first the pressure should be light, then 
 gradually increased until the deeper structures are reached. 
 Note tone, fluctuation, irregularities, displacement of parts, and 
 tenderness, all of which are necessary to differentiate between 
 tumors, fecal impaction. exudates, enlargement or distention of 
 organs, displacement of viscera, etc. A CONTRACTURED CONDITION 
 
 OF THE ABDOMINAL WALLS IS SUGGESTIVE OF SOME IRRITATIVE 
 
 DISEASE OF THE VISCERA, COVERED BY IT. Hilton explained 
 such conditions by the assumption that the NERVE SUPPLY OF 
 A viscus and ITS COVERINGS COMES FROM THE SAME SOURCE. A 
 hard, unyielding abdominal wall is symptomatic of PERITONITIS, 
 acute, if fever and tenderness exist; chronic peritonitis with ad- 
 hesions, if there is neither fever nor tenderness. A tightening 
 of the tissues beneath the wall should be noted and carefully 
 palpated, since such are indicative of adhesions. PERITONEAL ad- 
 hesions, whether from an operation or inflammation from other 
 causes, can often be diagnosed in this way. 
 
 If tenderness is found, as certain what organ is affected, whether 
 the uterus or its appendages. Tenderness immediately above the 
 pubic bones indicates cystitis, congestion or inflammation of 
 the uterus; tenderness on either side of the median line below 
 the umbilicus, disease of the Fallopian tubes or ovaries. Sore- 
 ness on either side of the umbilicus indicates, if deeply seated, 
 an enlargement of the lymphatic glands which drain the uterus. 
 This is indicative of uterine inflammation. In such cases a soft
 
 FIG. 44. Twisted pelvis, slightly exaggerated. (From photo of author's ease.)
 
 METHOD OF EXAMINATION. Ill 
 
 tumor varying in size from that of a marble to a walnut is found 
 at this point. 
 
 In diseased conditions of the uterus, pulsation or throbbing 
 of the arteries in the neighborhood of the uterus is frequently 
 found. In case of ovarian trouble this pulse is found along the 
 course of the iliac arteries. If this THROBBING is found in the 
 neighborhood of the UMBILICUS or immediately above, it indi- 
 cates some intestinal trouble. If found at the PIT of the stomach 
 it is a symptom of gastric trouble, usually catarrh. This throb- 
 bing becomes very painful at times, even preventing sleep by 
 its constant, annoying, hard pulsation. I have seen cases in 
 which the bed was shaken by this throbbing at each heart beat. 
 It is supposed to be caused by a local constriction of the artery 
 due to vaso-motor irritation. 
 
 Care should be taken in palpating just below the umbilicus 
 
 not tO MISTAKE THE BODY OF THE FIFTH LUMBAR FOR AN ANEU- 
 RISM. Patients wi 1 come with a supposed aneurism of the iliac 
 artery, there being found a localized tumor with pulsation. This 
 is particularly true of thin patients. The tumor is the body of 
 the fifth lumbar; the pulsation the result of pressure on the iliac 
 artery. Sometimes tumors are found, either uterine or ovarian, 
 which are mistaken for impaction or vice versa; the character 
 of the enlargement indicating which it is. If the TUMOR is IRREG- 
 LAR and nearly round or globular it points to a fibroid tumor; 
 if oblong and there is a history of constipation and reflex gastric 
 disturbances, it points to an impaction of the colon. 
 
 Another test for determining whether the tumor is of abdom- 
 inal or pelvic origin is made by ATTEMPTING TO PASS THE HAND 
 DOWNWARD JUST ABOVE the SYMPHYSis pubis. If the tumor 
 is PELVIC and rising into the abdominal cavity, the hand CAN 
 NOT BE PRESSED BELOW the tumor; but if abdominal, it CAN BE
 
 112 DISEASES OF WOMEN. 
 
 SUNKEN INTO THE PELVIC CAVITY below the tumor. Some men- 
 tion the presence of intermittent contractions in fibroid tumors; 
 these contractions can be felt in some soft fibroids, not in all. 
 
 The temperature of the abdominal wall should be noted. A 
 cold or clammy condition of the abdominal wall is indicative of a 
 lowered vitality of the parts covered by it. Some form of uter- 
 ine disease is usually present in such cases. If it occurs in the 
 region of, or follows the course of a nerve trunk, it can safely 
 be attributed to a lesion of the rib or vertebra in relation. The 
 "Old Doctor" says in reference to a general coldness of the abdo- 
 men that "THE OMENTUM is DISPLACED." When we consider 
 the position and form of this peculiar apron-shaped structure, 
 such a thing seems very reasonable. In dissections made by 
 the author the omentum was found to be displaced or diseased 
 in many subjects, and in all in which uterine disease had existed. 
 A hot, dry abdominal wall suggests peritonitis especially so if 
 the integument is reddened. Dryness of the skin often accom- 
 panies kidney disease and is suggestive of uremic disturbances. 
 In such cases there is a pasty complexion, loss of strength and 
 dysmenorrhea. 
 
 By PERCUSSION is ascertained the solidity of the enlarge- 
 ment. In ascites the percussion note is changed with different 
 positions of the patient. If the patient is placed on the back, 
 dullness is elicited by percussion on the sides, while in the median 
 line the percussion note is flat or tympanitic. If the abdomen 
 is swollen and tympanitic, it is due to gas in the bowels; or if it 
 is also tender, to peritonitis, which most often follows a sudden 
 cessation of the menses. 
 
 Sometimes AUSCULTATION is used in cases of suspected aneu- 
 rism and in some other abdominal enlargements. In an aneu- 
 rism a BRUIT is heard almost svnchronous with the heart beat.
 
 METHOD OF EXAMINATION. 113 
 
 Vascular murmurs or SOUFLES may also be heard over large 
 uterine tumors and the gravid uterus. FETAL heart sounds are 
 detected as early as the fourth month of pregnancy and are com- 
 pared to the ticking of a watch beneath a pillow. FRICTION 
 sounds are sometimes detected in chronic peritonitis. 
 
 EXAMINATION OF THE VULVA. It is seldom necessary 
 to use inspection of the vulva in the examination of gynecologi- 
 cal cases. A routine practice of such an examination is to be 
 condemned unless there are indications, and good ones at that, 
 of vulvar disease. On the other hand, this form of examination 
 affords information as to the CLEANLINESS of the patient, ELONGA- 
 TION or HYPERTROPHY of the LABiA, size of the clitoris or ADHERED 
 
 PREPUCE, VAGINAL DISCHARGES, and the ANOMALIES of the HYMEN 
 
 or its remains, which things are important in many cases. As a 
 rule INSPECTION of the external genitals SHOULD BE made when 
 there is PAIN, SORENESS, PRURITUS or SWELLING; in the young 
 when MASTURBATION is suspected, since it affords the best evi- 
 dence. When the patient speaks of something having "DROPPED 
 DOWN," which term is used by the laity to describe procidentia, 
 inspection is indicated. The patient should be placed in the 
 dorsal position with the limbs flexed and separated. It is best 
 to use an endoscope with a small electric light, or better still 
 reflected sunlight by means of a mirror held directly in the sun- 
 shine. By these means the parts can be thoroughly inspected 
 with little exposure of, or embarrassment to the patient. HEM- 
 ORRHOIDS, if present, will be the first abnormal condition noticed. 
 The external forms, which are usually fibrous in character, can 
 be seen as a bunch or protrusion around the anus. The SIZE 
 and CONDITION of the LABIA are next noted; the nymphae being 
 large, red and irritable in cases of masturbation. Separation 
 
 of the greater lips then reveals the condition of the vulva, whether 
 
 s
 
 114 DISEASES OF WOMEN. 
 
 or not there, is inflammation, growths, a swollen condition or 
 prolapsus of the walls. By causing the patient to STRAIN, as at 
 stool, the DEGREE OF PROLAPSUS of the vaginal walls is the better 
 ascertained. There may be tears of the perineum and labia 
 produced by parturition. There may be irritable spots caus- 
 ing VAGINISMUS. These localized spots of irritation often 
 result from an imperfectly healed hymen which has been 
 ruptured. Awkward coitus, the use of instruments, astring- 
 ents or very hot douches frequently injure the vulva, thus setting 
 up an irritation. If the patient is a young girl and masturba- 
 tion is suspected, the diagnosis can usually be made by examina- 
 tion of the clitoris and lesser lips, they being found irritable and 
 inflamed. The meatus urinarius should be examined for dis- 
 eased conditions since it often presents a red, angry appearance 
 in many types of uterine disease. In CHRONIC GONORRHEA, it 
 is RED and IRRITABLE and remains thus for many years after a 
 severe attack of gonorrheal urethritis. Occasionally a CARUNCLE 
 is discovered attached to the meatus and is the cause of much 
 local discomfort and inconvenience. 
 
 EXAMINATION OF THE VAGINA. VAGINAL EXAMINA- 
 TION should not be made in GIRLS NEAR THE AGE OF PUBERTY 
 UNLESS, by other methods, you have failed to diagnose and cor- 
 rect the cause of the disease. In the case of unmarried women 
 it should not be attempted, unless the indications for such an 
 examination are very strong. These indications are PERSIST- 
 ENT BACKACHE at or below the small of the back, HEADACHE, 
 
 NECKACHE, MENSTRUAL pain, BLADDER DISTURBANCES. HEM- 
 ORRHOIDS, aching of limbs and constipation. If the above dis- 
 orders do not yield to external treatments, at least a vaginal 
 examination, should be given. If you have a patient belong- 
 ing to either class remember that the rectal examination is usual-
 
 METHOD O*F EXAMINATION. 115 
 
 ly sufficient, and avoid if possible the vaginal examination. 
 Reed says: " Youth and virginity should always be looked 
 upon as contraindications for such an exploration unless in the 
 presence of counter-balancing reasons: such, for instance, as the 
 presence of all the menstrual phenomena, the flow excepted, 
 suggesting the possible retention of the menstrual fluid; or in 
 the presence of an offensive discharge associated with remote 
 pelvic symptoms; or to investigate the origin of persistent hem- 
 orrhage." It is even useless in many of the above cases. The 
 average physician is TOO PRONE to make such examinations on 
 the slightest provocation, which often do more harm than good. 
 
 On the contrary, in the case of a married woman whose 
 symptoms point to a pelvic disease, always make the examina- 
 tion. If the patient has passed the menopause, all symptoms 
 of a pelvic character should be regarded with suspicion, and 
 measures adopted for a thorough examination, especially if 
 hemorrhage has occurred. Examinations should not be made 
 when the patient is menstruating unless there is an acute dis- 
 placement causing painful reflex troubles ; it being disagreeable and 
 sometimes injurious. Always secure the consent of the patient 
 to be examined, or that of an immediate relative or guardian; 
 never making a vaginal examination without it. 
 
 POSITIONS. The principal positions used for examining 
 a gynecological patient, are the Sims and dorsal. The other 
 positions used are the erect, GENU-PECTORAL and TRENDELEN- 
 BERG, that is, with the hips elevated. 
 
 In making the examination of a patient in the DORSAL POSI- 
 TION, the patient should lie with her heels about six inches apart 
 and the knees widely .separated. All bands and constrictions 
 around the abdomen should be removed. The bladder and 
 bowel should be evacuated before a vaginal or rectal examina-
 
 116 
 
 DISEASES OF \frOMEN. 
 
 tion is attempted. Usually it is not necessary to expose any 
 part in making the digital examination. The dorsal position is 
 used in making the bimanual examination, and in mak ing an 
 
 FIG. 45. Lymphatic glands of lumbar region that drain the uterus. 
 
 examination with the bivalve speculum. For the digital exami- 
 nation the Sims position is to be preferred for reasons named 
 below.
 
 METHOD OF EXAMINATION. 
 
 117 
 
 In the Sims position the patient lies on her left side, half 
 turned over on the front ; both limbs are flexed, the right slightly 
 
 t 
 
 FIG. 46. Sims position. 
 
 more than the left; the left side of the face rests on the pillow, 
 the left breast touches the table and the left arm is placed behind 
 the body. I prefer this position in examination, first, because 
 a higher exploration of the pelvic cavity can be made; second, 
 by turning the patient into the dorsal position you can make 
 the bimanual examination; third, you have the advantage of 
 both positions without withdrawing the finger; and fourth, the 
 patient's face is turned from you thus relieving her of embarass- 
 ment. Backward displacements of the uterus can be corrected 
 at the time of examination with the patient in this position ; which 
 is not easily done with the patient in the dorsal position. The 
 Sims speculum, which is probably the best one for ordinary use, 
 is used only in this position.
 
 118 
 
 DISEASES OF WOMEN. 
 
 The genu-pectoral position is used principally in treating; 
 that is, in replacing a retro-deviation or introducing a tampon, 
 
 FIG. 47. The genu-pectoral position, 
 
 rather than for diagnostic purposes. The patient rests on her 
 knees, upper part of the chest, left side of the face and right 
 fore-arm. The thighs should be perpendicular, the uterus then 
 if in position, has a tendency to assume the vertical position 
 with the heavy end or fundus down. The tendency of the uterus 
 to assume the perpendicular when the patient is in the genu- 
 pectoral position is an important point in the treatment of all 
 displacements. A great many displacements can be cured 7 by 
 the patient placing herself in this position once or more times 
 a day for some time.
 
 METHOD OF EXAMINATION. 
 
 119 
 
 The erect position is used in the examination of cases of sus- 
 pected prolapsus; the degree of prolapsus being better ascer- 
 tained if it is made in this position. The patient should be on 
 the physician's left with the left foot resting on the round of 
 the stool. The physician should sit on the stool at the pa- 
 tient's left and introduce the index finger of the right hand into 
 the vagina. 
 
 The Trendelenberg position is seldom used for diagnostic 
 purposes, but is used in operations on the abdomen, in treating 
 
 FIG. 48 TreiHlelenbers position. 
 
 a prolapsed condition of the bowels or anteflexion of the uterus. 
 In this position the intestines are drawn off the pelvic organs, 
 and is a position to be recommended in the treatment of all ante- 
 deviations of the uterus.
 
 120 DISEASES OF WOMEN. 
 
 VAGINAL EXAMINATION. In making the VAGINAL EX- 
 AMINATION I make it a practice to place the woman on her left 
 side or in the Sims position for the above mentioned reasons, 
 then turn her over on her back for the performance of the biman- 
 ual if it can not satisfactorily be made with her on the side. The 
 index finger of the right hand should be carefully lubri- 
 cated with glycerine, vaseline or some other suitable lubricant. 
 With the left hand the clothes can be cleared away from the 
 hips so as to make a passage for the examining finger, which is 
 passed onward until it reaches the cleft between the buttocks; 
 the finger is next passed forward over the anus, perineal body 
 and fourchet until the pulp of the finger reaches the vaginal 
 orifice. By doing this the clitoris is avoided, thereby prevent- 
 ing sexual irritation and contraction of the muscles of the peri- 
 neum. The physician must be careful not to pass the finger into 
 the rectum by mistake. This can be avoided if their axes are 
 remembered, the axis of the vagina being upward and back- 
 ward; that of the rectum, upward and forward. No FORCE is 
 required to pass the finger into the vagina of a woman whose 
 hymen has been ruptured, whereas some force is necessary to 
 overcome the resistance of the sphincter ani. The finger, now 
 being at the vaginal orifice, should be carried backward and up- 
 ward along the walls of the vagina until its upper limits are felt. 
 While doing this the physician should NOTE: FIRST, the CONDI- 
 TION of the PELVIC FLOOR and VAGINAL orifice, if there is loss of 
 tonicity, which makes the vagina patulous, the absence or pres- 
 ence of tender spots which produce a spasm or contraction; 
 SECOND, the WALLS, condition of the RUGAE, whether there is 
 absence or presence of the same; examine for secretions, heat, 
 tumors attached to the walls, for foreign bodies such as pessaries 
 that have been placed there for the purpose of treatment; also
 
 METHOD OF EXAMINATION. 
 
 121 
 
 note the length and condition of the walls and the condition of 
 
 the anterior and posterior fornices. 
 
 THIRD, note the cervix, its 
 size, shape and consistency 
 of the lips, they being of about 
 
 the CONSISTENCY OF THE END 
 OF THE NOSE if HEALTHY, 
 
 and about the CONSISTENCY 
 
 OF THE LIPS if DISEASED Or 
 
 if PREGNANCY exists. The 
 shape of the cervix is conical 
 with a smooth surface. Its 
 size varies, it usually pro- 
 jecting into the vagina about 
 one inch and is about three- 
 quarters of an inch in diam- 
 eter. As a rule it looks 
 larger than it feels. Examine 
 carefully to ascertain if it is 
 drawn to one side, if fixed or 
 mobile, or if split with cica- 
 trices radiating from it to 
 the vaginal roof. Often in 
 such cases of marked lacera- 
 tion, one lip is bent consider- 
 ably, resembling in shape a 
 sled runner. If both lips 
 diverge, the name "bell 
 shape" has been applied. 
 The lip on the concave side 
 
 FIG. 49. Different forms of abnormal , , i j a 
 
 cervices, is elongated m marked riex-
 
 122 DISEASES OF WOMEN. 
 
 ions. Often in an infantile uterus there is a cervical flexion. If 
 the CERVIX is markedly CONICAL or pointed, it points to under- 
 development, perhaps an INFANTILE UTERUS. If cylindrical and 
 the end appears to be obliquely truncated, an error in develop- 
 ment is also indicated, and sterility is the common sequel. 
 
 Note the direction of the cervix and its relation to the 
 vaginal walls, because the diagnosis between a version and a 
 flexion depends upon the position of the cervix. The tip of the 
 coccyx can be felt on a level with the end of the cervix. This 
 can best be ascertained with the patient in the dorsal position. 
 
 FOURTH, note theos, its SIZE and SHAPE; it being a dimple 
 in the nullipara, a transverse slit in the mulitparous woman. 
 (See Figs. 17 and 18.) The cervix may be slit onone or both sides, 
 thus destroying the os externum and more or less exposing the 
 cervical canal. This permits of a protrusion of the endometrium, 
 such condition receiving the name of ECTROPION. Bodies pro- 
 jecting through the os should be noted, such as polypi, can- 
 cerous masses, stem pessaries or fragments of abortion. In the 
 infantile uteras the os is very small; in most cases of subin volution, 
 it is patulous. The next thing to be noted is the corpus uteri 
 or body. By bringing pressure against the anterior fornix with 
 the examining finger, the uterus can be felt if it is in normal posi- 
 tion or ante-deviated. It moves readily with slight pressure; 
 the cervix also changing its position. 
 
 The OVARIES AND FALLOPIAN tubes if normal, can be felt 
 with difficulty in a favorable subject. If the patient is large 
 or the abdominal wall tender, they can not be outlined ; but in 
 ordinary cases they can be distinguished if congested, inflamed 
 or displaced. Pressure on a diseased ovary, causes a pain to be 
 referred to the iliac fossa of the corresponding side. 
 
 FIFTH, the POSTERIOR FORNIX is concave when felt from below
 
 METHOD OF EXAMINATION. 
 
 123 
 
 upward; normally, it has the feeling of the inside of the angle of 
 the mouth. Note whether this cavity is lessened by the presence 
 of adhesions or some foreign body. See if any lump can be felt 
 projecting from the pouch of Douglas. A body felt through the 
 posterior fornix is usually a retro-deviated uterus, but may be a 
 prolapsed ovary, feces or a fibroid tumor attached to the pos- 
 terior wall of the uterus. 
 
 SIXTH, examine the ANTERIOR FORNIX ; note its shape, depth, 
 and if any body can be felt through it. If so, it is usually the 
 anteflexed uterus or a fibroid tumor. This fornix may be im- 
 pinged upon by retroversion of the uterus, or the cervix and the 
 
 FIG. 50. The bimauual examination in the dorsal 
 posture. (By ford from Shrocder.) 
 
 vaginal wall may have grown together as a result of a vaginitis; 
 this sometimes obliterating both the anterior and posterior 
 fornices. 
 
 From this examination we have learned of the TONE and 
 POSITION of the cervix, CONSISTENCY of the vaginal walls and size 
 of the external os, these being only preliminary to the bimanual 
 examination. 
 
 BIMANUAL EXAMINATION. The bimanual method is
 
 124 
 
 DISEASES OF WOMEN. 
 
 one of very great importance in the examination of the pelvic 
 contents, and is used very extensively by the osteopath. It 
 consists of palpation of the uterus between the hands, one internal 
 and the other external. This is done in two ways, per vagina 
 and per rectum. It is performed with the patient in the dorsal 
 
 FIG. 51. Biimvnual examination of the uterus per rectum. 
 
 or Sims position, preferably the former, with the limbs flexed. 
 After making a digital examination in the Sims position, if 
 the bimanual can not be satisfactorily made while in that posi- 
 tion, turn the patient into the dorsal position without removing
 
 METHOD OF EXAMINATION. 125 
 
 the internal finger. With right index finger (sometimes second 
 finger also) in vagina against the cervix, and the left with the 
 ulnar side superior to the uterus, which prevents retro-displace- 
 ment, by approximating the two hands, the uterus can be felt 
 as a lump or body between them if it is in normal position, ante- 
 flexed or anteverted; but if it is retro-displaced the tips of the 
 fingers can be distinctly palpated, the tissues alone separating 
 them. Sometimes in cases of anteversion it is hard to reach the 
 cervix, and in order to lengthen the examining finger the remain- 
 ing fingers of the hand should be tightly flexed, and considerable 
 pressure brought to bear on the perineal body. This causes no 
 pain and by so doing the physician can reach at least one 
 inch further along the cleft between the nates. The external hand 
 should be steadily, not spasmodically, depressed, the pressure 
 being gradually increased until the deep structures can be out- 
 lined. 
 
 The OBJECT of the bimanual examination is to determine 
 the POSITION, size and SHAPE of the UTERUS, and to recognize 
 any ENLARGEMENT or growth that may be in the pelvis; also to 
 confirm the diagnosis made by external and vaginal examina- 
 tion. The CONDITION OF THE ADNEXA is also ascertained by this 
 method. By pressure with the external hand, the uterus being 
 steadied by the internal finger, the broad ligaments, tubes and 
 ovaries, if at all diseased, can be outlined. In normal cases they 
 can with difficulty be outlined. In order to differentiate between 
 the normal and abnormal, it is necessary to know what is found 
 in a normal case by vaginal and bimanual examinations. The 
 following is a description of the conditions found in a nulliparous 
 married woman on vaginal and bimanual examination: "The 
 ostium vaginae is patulous and admits two fingers; vaginal 
 walls moist, and rugous, with no abnormalities; vaginal portion
 
 126 DISEASES OF WOMEN. 
 
 of cervix normal in size; os uteri felt like a dimple looking down- 
 ward and backward. No bodies are felt through the lateral 
 and posterior fornices, which are concave on the vaginal aspect 
 and have the feeling on pressure of the angle of one's mouth. 
 In the anterior fornix a body is felt, which on bimanual examina- 
 tion is discovered to be the uterus lying to the front and not 
 enlarged. The vagina and cervix meet at about a right angle. 
 Bimanual exploration of the posterior fornix reveals nothing dis- 
 tinctly palpable. The PATIENT COMPLAINS OF NO PAIN DURING 
 THE WHOLE EXAMINATION and has no symptoms referable to the 
 pelvis. ' ' 
 
 In case there is inflammation of the vagina or of the uterus, 
 bimanual examination is difficult and the rectal examination 
 should be substituted. The examination is also difficult in stout 
 nulliparous women in whom the abdominal walls are very thick. 
 AT FIRST, the BIMANUAL method is UNSATISFACTORY, but by 
 perseverance it becomes more satisfactory in recognizing uterine 
 displacements and pelvic growths. It is a very important ex- 
 amination and by practice wonderful accuracy of touch can be 
 acquired. 
 
 The OBJECT of these various methods of examination is to 
 ascertain (1) the amount of TENDERNESS and inflammation; (2) 
 degree of mobility, which mobility is determined by the presence 
 and extent of exudates and adhesions; and (3) the position of 
 the uterus, which is the least important as compared with the 
 other two. 
 
 A TENDER, inflamed uterus is ALWAYS pathological and needs 
 treatment. An IMMOBILE uterus is usually pathological. If 
 tenderness complicates the loss of mobility it is PATHOLOGICAL 
 IN EVERY case. If, on palpation, no tenderness is found in the 
 uterus, I doubt the advisability of giving local treatments even
 
 METHOD OF EXAMINATION 1 . 
 
 127 
 
 though adhesions are present, unless there are pressure symp- 
 toms. A DISPLACED UTERUS IS NOT ALWAYS PATHOLOGICAL and 
 
 replacement should not be attempted unless congestion or in- 
 flammation is present, in which case there will be tenderness on 
 palpation. In some cases PRESSURE symptoms accompany the 
 displacement, in which cases the uterus should be replaced. 
 
 EXAMINATION WITH THE SPECULUM. The speculum 
 is an instrument so arranged that the two vaginal walls can be 
 separated, bringing the os, cervix, and parts of the vaginal walls 
 into view. There are various kinds of specula which pattern 
 after two forms, the univalve or Sims and the bivalve 
 
 The Sims speculum consists of two blades of unequal size 
 running at right angles to a shank which unites them. The 
 smaller blade is used for the examination of nullipara, the larger 
 
 FIG. 52. Sims speculum. 
 
 for examining women with large vaginae, and for operating. It 
 acts as a retractor, pulling the posterior wall from the anterior, 
 thereby admitting air into the vagina, and exposing the upper 
 part of the canal with the cervix and vaginal wall. 
 
 To INTRODUCE the speculum, the patient should be in the 
 Sims position, which has been previously described. If the 
 INTROITUS VAGINAE is small, the upper or right buttock and labium 
 should be lifted by the left hand, then the instrument, which has
 
 128 
 
 DISEASES OF WOMEN. 
 
 been previously warmed and oiled, should be taken hold of with 
 the right hand, and the blade, held in line with the vaginal axis, 
 gradually pressed into the vagina, keeping it well back against 
 THE POSTERIOR WALL. To successfully do this remember the 
 AXIS of the vagina; it being toward the hollow of the sacrum, not 
 in the long axis of the body. 
 
 The ADVANTAGES of this speculum are, its easy introduction, 
 its simplicity, the freedom from pain in its use, the view it gives 
 of the different parts IN THEIR NORMAL POSITION, especially the 
 anterior vaginal wall, and the advantage it gives for manipula- 
 tion of the uterus with other instruments if such are used. The 
 DISADVANTAGE is that it is necessary to have an assistant to hold 
 it in order to make a satisfactory examination. 
 
 The BIVALVE SPECULUM consists of two blades so hinged 
 
 together that they may be sepa- 
 rated by pressure on a lever. 
 To introduce the bivalve spec- 
 ulum, the woman should be in 
 the dorsal position with the 
 vulva exposed ; the two lips are 
 separated with the left hand, 
 the point of the instrument, 
 after it has been warmed and 
 lubricated, is introduced in 
 imllipara, so as to conform with 
 
 Fm.53.-Blvalve speculum. the extemal ope ning, but as 
 
 soon as the point enters it should be turned so that the blades 
 become antero-posterior. In multipara it is not necessary to 
 start the speculum in edgewise but introduce directly without 
 turning. The instrument should then be lightly pressed inward, 
 downward and backward until it reaches the cervix. The blades
 
 METHOD OF EXAMINATION. 129 
 
 are then opened and, as soon as the cervix is brought to view, 
 are fixed with a screw. The os and cervix can be seen by the 
 use of this instrument, but they are forced into a distorted 
 position, thus the uterus is so changed that its position can not 
 be accurately diagnosed by the use of this kind of a speculum. 
 There are various forms of these specula which differ in size, 
 manner of separating the blades and the material out of which 
 they are made. 
 
 Next comes the question when should a speculum be used? 
 In my practice I have very little use for a speculum and seldom 
 use it, and the longer I am in practice, the less use I have for instru- 
 ments in general and specula in particular. If I have a case of 
 erosion of the cervix, of some fungus formation that I cannot 
 differentiate by digital examination from a laceration or cancerous 
 growth, an examination with a speculum is indicated. Some- 
 times it is used in the introduction of a sound, but I think in most 
 cases that is unnecessary. It is used by some physicians in order 
 to tampon the vagina or introduce a pessary, but these should 
 not be used by the osteopathic physician except in rare cases, 
 hence the speculum is not a necessary instrument even in these 
 cases. 
 
 The ENDOSCOPE is used to illuminate the cavity of the vagina 
 when a speculum is used, and is very useful since the patient can 
 be examined in a dark room or at least not in front of a window. 
 It consists of an electric battery connected with a one or more 
 candle power lamp with a contrivance for attachment to the 
 speculum. The use of a MIRROR, by which the sun light can be 
 reflected and focussed directly on the parts exposed, makes the 
 best possible light that can be obtained. The disadvantages 
 are that an assistant and the direct rays of the sun are needed. 
 
 I want to condemn the use of the speculum as is ordinarily 
 
 9
 
 130 DISEASES OF WOMEN. 
 
 practiced by the physician. The exposure and nervous shock, 
 in making the examination do more harm than good, in most 
 cases. Again, the practice of using it from one to six times 
 each week, weakens the vaginal walls, admits air into the uterus, 
 and has a tendency to produce displacements by stretching the 
 vaginal walls and changing the intra-pelvic air pressure. 
 
 THE SOUND. The uterine sound consists of smooth nickel 
 or silver plated copper wire, blunt at the point and with cor- 
 rugated flat handle, as shown in Fig. 54. 
 
 Fi<; 54 Flexible sound. 
 
 It can be bent into various shapes so that it will accomo- 
 date itself to the various displacements of the uterus. It is used 
 more for therapeutical than for diagnostic purposes. In diag- 
 nosis it is used to ascertain the length of the uterine cavity, the 
 size of the canal, mobility of the uterus and its position in the 
 pelvis. For therapeutical purposes it is used to correct displace- 
 ments, especially flexions. I think its use is abused in a great 
 many cases. The uterus is lined with a delicate mucous mem- 
 brane or endometrium and can be readily injured, or the wall 
 punctured by the introduction of any foreign body such as a 
 probe or sound. 
 
 If the os is patulous a very blunt steel dilator like the one 
 shown in Fig. 55 should be used if one is used at all, instead of 
 the small flexible sound. As far as its diagnostic use is indica- 
 ted, the length of the uterus, size of the os, mobility and posi- 
 tion may all be ascertained by digital and bimanual examina- 
 tion. As regards its therapeutical use, I sometimes use it in
 
 METHOD OF EXAMINATION. 131 
 
 flexions or acute displacements if I have failed by other methods, 
 while other displacements such as versions and prolapsus can be 
 corrected by the use of the wire uterine repositor or manually. 
 To INTRODUCE the sound into the uterus, the patient is 
 placed in the latero-prone or Sims position with the thighs well 
 up. The instrument is taken lightly by the handle in the left 
 hand, while the point of the forefinger of the right hand is carried 
 up to the os uteri, which is felt and its direction and the position 
 of the uterus ascertained. This is important to know because a 
 flexion might exist and unless the sound were introduced to cor- 
 respond to the bend the uterine wall might be injured. The 
 
 FK;. 55. Steel sound. 
 
 sound, after it has been warmed and lubricated, is introduced 
 along the finger with the concavity toward the perinea! body and 
 the handle directed backward. By following the course of the 
 finger the end of the sound comes in contact with the os uteri, 
 and with a little manipulation enters the cavity of the uterus. 
 It is then carried along the cervical canal and the handle turned 
 with a general sweep so as to bring the concavity anterior instead 
 of posterior, thus corresponding to the uterine canal. It is then 
 gently pushed forward until it reaches the fundus uteri, which 
 is ascertained by a slight sense of resistance that is felt to the 
 onward passage. If the introduction causes very much pain, it 
 indicates that something is wrong and one should withdraw the 
 sound or not introduce it at all. Again, in certain softened states 
 of the uterus, such as metritis and subin volution, it would be 
 possible to penetrate the wall and still cause very little pain.
 
 132 DISEASES OF WOMEN. 
 
 Some physicians use a speculum, to aid in the introduction 
 of the sound. By exposing the os uteri by means of a bivalve 
 speculum, the point can be readily introduced into the uterus. 
 The speculum is in the way if the sound has to be turned, and 
 besides it takes a longer time to perform the operation than with- 
 out it. It has this advantage the sound can be kept clean so 
 that no infection will be carried into the diseased uterine cavity. 
 
 The usual difficulties experienced in passing the sound are 
 caused by stenosis of the canal or displacements of the uterus, 
 such as flexions. If the sound meets with resistance, it should 
 be withdrawn or slightly turned; since the diseased uterine wall 
 may be readily injured and perforated; NEVER USE FORCE IN ITS 
 INTRODUCTION. If the patient is anxious for you to use a sound, 
 be very careful LEST THERE BE PREGNANCY, the introduction 
 usually resulting in abortion. As I said before, its use is contra- 
 indicated in most of the cases and should not be used indiscrim- 
 inately. The WIRE UTERINE REPOSiTOR invented by Dr. Still 
 takes the place of the uterine sound as a therapeutical agent 
 and should be used if possible in preference to the sound. 
 
 THE RECTUM. The results obtained by vaginal examina- 
 tion are limited by the fact that the finger cannot be pressed very 
 much higher than the reflection of the vaginal walls which form 
 the fornices; although they can be stretched, the finger in too 
 short to reach very high. This is partly overcome by the pres- 
 sure of the upper hand in performing the bimanual, but in other 
 cases in which the bimanual is unsatisfactory and it is not prac- 
 tical to make the vaginal, rectal examination is substituted. 
 Schultze says: "To find out some of the anomalous positions 
 of the uterus and their causes, it is often indispensable 
 to palpate high up behind it, and to do so PER VAGINAM is gen- 
 erally impossible; we can reach much farther up on the cervix,
 
 METHOD OF EXAMINATION. 133 
 
 even with one finger in the rectum, than in the vagina. By 
 introducing two fingers up the rectum we can reach across the 
 fundus uteri, to the fingers of the other hand, feeling through the 
 abdominal wall, and make a complete examination of the whole 
 cavity of the pelvis with ease when this is impossible from the 
 vagina." (See Fig. 51.) In the case of virgins, I usually make 
 the rectal examination first, and if that is not satisfactory, and 
 the case does not yield to treatment, I then make the vaginal. 
 
 The rectum should be emptied, preferably by the use of an 
 enema. The examiner should be sure the finger nail is not long 
 or rough, the mucous membrane of the rectum being highly 
 sensitive. The finger should be thoroughly lubricated, vaseline 
 being best and most commonly used. The pulp of the finger 
 should then be placed against the external sphincter and 
 there held an instant until the resistance is overcome; then grad- 
 ually force the finger forward and upward, noting the condition 
 of the walls, the sphincters, mucous membrane, the presence 
 of piles, fissures, ulcers, etc. Next turn the pulp of the examin- 
 ing finger so that it lies on the anterior rectal wall, through 
 which can be felt the cervix. If the uterus is in normal posi- 
 tion this is the only part that can be felt through the anterior 
 rectal wall. By feeling on either side of the uterus with pressure 
 on the abdomen, the ovaries, tubes and ligaments can be detected. 
 
 The OBJECT of the RECTAL examination is to verify the bi- 
 manual examination, to take the place of the vaginal and to 
 locate cause of rectal, as well as uterine disorders. In cases of 
 displacements of the uterus the diagnosis frequently depends 
 upon the rectal examination. In FORWARD DISPLACEMENTS the 
 fundus is NEVER FELT on rectal examination, while in BACKWARD 
 DISPLACEMENTS it is ALWAYS felt. In retro-deviations some- 
 times rectal treatment is given while in the genu-pectoral posi-
 
 134 DISEASES OF WOMEN. 
 
 tion in the effort to force the uterus forward into its normal 
 place. In cases of chronic constipation, prolapsus of the bowel 
 or hemorrhoids, I usually make a rectal examination, since the 
 cause of the trouble is frequently best ascertained in this manner. 
 Sometimes the hemorrhoidal condition or ulceration is beyond 
 the reach of the finger when examined in the usual way, that is 
 in the latero-prone position. If, in such cases, the patient is 
 examined while in the SQUATTING POSTURE, one can reach an 
 inch or more higher, and the condition correctly diagnosed. The 
 author has treated cases of this sort. There were constrictions 
 of the bowel, too high to be reached when the patients were 
 examined in the lateral position, but by examining them in the 
 above mentioned way the folds in the bowel were reached and 
 with the assistance of the external hand, by which the bowel 
 was pulled upward, completely removed. 
 
 THE BLADDER AND URETHRA. The intimate vascu- 
 lar and nervous connection with, and the proximity of the 
 uterus to, the bladder, result in symptoms of many uterine dis- 
 eases being referred to the bladder, and in cases in which the 
 bladder is affected, it is sometimes necessary to make an exami- 
 nation of that organ, which is accomplished principally by pal- 
 pation. Disturbance of micturition, such as PAIN at or just 
 following the completion of the act, INABILITY TO RETAIN the 
 urine or frequent micturition, INVOLUNTARY ESCAPE of urine 
 on coughing or other exertion, feeling of WEIGHT and discom- 
 fort over the pubes, backache early in the morning BEFORE EVAC- 
 UATION of the bladder, changes in the urine, such as the pres- 
 ence of pus, triple phosphates or MARKED ACIDITY, and the pres- 
 ence of tenderness just above the symphysis pubis, indicate CYS- 
 TITIS or some other form of bladder trouble. Such symptoms, 
 primarily indicate, in many cases some form of uterine trouble
 
 METHOD OF EXAMINATION. 135 
 
 especially metritis, the bladder disturbances being secondary. 
 Various instruments have been invented for the purpose of ex- 
 amining the inside of the bladder, but I regard them as useless 
 in most of the cases in which they are used, and in many, posi- 
 tively injurious since INCONTINENCE OF URINE often follows as a 
 result of dilatation of the urethra, which is necessary in instru- 
 mental examination of the bladder. The bladder is a closed 
 viscus and should be left severely alone and no instruments in- 
 troduced, except in cases of CALCULI in the bladder or RETEN- 
 TION OF URINE, in which latter case a catheter should be used to 
 relieve the distention. 
 
 In enlargement of the bladder from retention of urine there 
 exists a rounded tumor above the symphysis, which can be seen 
 as well as palpated. Pressure on it produces a desire to mic- 
 turate. Percussion aids in diagnosis, a dull note being elicited. 
 Cystocele can also be determined by palpation as well as inspec- 
 tion. Sensitive points in the urethra and often calculi of bladder 
 can be diagnosed by palpation through the anterior vaginal wall. 
 If the calculi are very large the diagnosis is comparatively easy. 
 
 In cases of vaginismus or stenosis of the vagina from any 
 cause, copulation may take place in the urethra. The writer 
 saw one case of this kind. The urethra had become so elastic 
 that complete contraction followed the copulative act, and there 
 was no dribbling of urine or other bladder disturbances. A 
 local urethritis is sometimes formed in cases in which a cystitis 
 or acidity of the urine exists. This, along with prolapsus of 
 the urethral mucous membrane, polypi and urethra caruncles 
 which are vascular growths at the meatus urinarius, can be diag- 
 nosed by inspection. In such conditions there is marked pain 
 on micturition which is often referred to the urethra, perineum 
 or spine.
 
 136 DISEASES OP WOMEN. 
 
 EXAMINATION OF THE PELVIS. In making an examina- 
 tion of the pelvis and lower dorsal region, first use inspection. 
 I usually have the patient sit on the edge of the table with her 
 back to me. After raising the garments so as to expose the back, 
 first notice the median furrow, its depth, whether flattened, 
 deepened or widened, and its direction. If furrow is deepened 
 it indicates an anterior condition of the spine or an atrophied 
 condition of the erector spin ae muscles which form the walls of 
 the median furrow; if flattened or obliterated, a posterior con- 
 dition ; if direction is changed, it indicates a scoliosis or lateral 
 curvature. If the spines are very much posterior, especially 
 in the lumbar region, the skin covering them will be discolored, 
 usually a yellowish brown. This is probably the result of pres- 
 sure on the spine resulting from the patient leaning against the 
 back of a seat. 
 
 In examining the patient in the sitting posture let her sit 
 naturally; that is, do not tell her to sit erect or bend forward, 
 
 the WEAK POINTS SHOWING BEST WHILE SHE SITS IN HER NATURAL 
 
 POSITION. If the patient does not sit as she ordinarily does, 
 the STRAINED CONDITION of the muscles obliterates some of the 
 weak parts. Compare the two innominate bones, notice if one 
 is higher or more prominent than the other, the full side usually 
 indicating the affected or diseased side. (See Fig. 44.) Note 
 the PROMINENCE and CURVE of the sacrum and the posterior spines 
 of the ilium, also the crease between the buttocks, whether it is 
 straight or deflected to one side; note also the SIZE of the buttocks 
 since the condition of the glutei muscles indicates, in a meas- 
 ure, the condition and activity of the genitalia. This is best 
 illustrated in women who have been married a short while, the 
 hips having become broadened and enlarged. Note the CON- 
 CAVITY OF THE WAIST line, the two sides seldom being alike. The
 
 METHOD OF EXAMINATION. 167 
 
 deeper or more abrupt the curve, the higher the innominate, 
 but if the fossa or curve is shallow and increased in length, that 
 side of the pelvis is lower than the opposite one, or the patient 
 has a lateral spinal curvature to that side. Note the INCLINA- 
 TION of the sacrum and the effect on the spinal column, whether 
 abnormally curved forward or whether flattened, thus indicat- 
 ing an absence of the normal curve. Now place the patient in 
 the dorsal position; compare the anterior superior spines of the 
 ilia, their height .and prominence. Note the LENGTH OF THE 
 LIMBS; it is best not to pull or stretch first one limb then the 
 other, to ascertain their length, but to let the patient lie naturally 
 on the table. SLIGHT SHORTENING in RECENT CASES indicates 
 an INNOMINATE lesion; slight lengthening, hip disturbances; 
 probably a partial dislocation. 
 
 PALPATION. In palpating the pelvis, I usually first sit 
 behind the patient, she either sitting or standing. By placing 
 both hands on the crest of the innominate bones, height and 
 prominence can be best ascertained. Ask the patient if she has 
 to pad her dress on one hip or if she notices one side being higher 
 than the other; frequently the patient discovers this in having 
 a dress fitted. The posterior spines should be compared as to 
 their HEIGHT, distance apart and PROMINENCE, also the dif- 
 ferent parts of the sacrum be outlined. Feel for irregularities 
 at the different articulations, and especially at the sacro-iliac 
 synchondrosis. A KNOTTED OR LUMPY condition can be felt at 
 this point in a great many cases, and is indicative of PELVIC DIS- 
 EASE and a subluxated innominate. This thickening is probably 
 the result of an enlargement of the lymphatic glands, or of the 
 escape of synovia from the sacro-iliac articulation. Note the 
 condition of the FIFTH LUMBAR, whether displaced or a tender- 
 ness exists; either one indicating pelvic trouble. Put some
 
 138 DISEASES OF WOMEN. 
 
 PRESSURE over the SCIATIC nerve at a point immediately behind 
 the trochanter, it being tender in NEARLY ALL cases of pelvic 
 inflammation. 
 
 Now turn the patient to the dorsal position, then by placing 
 the hands on the crests of the ilia, note their height, distance 
 apart of spines, direction and amount of flare of crest and whether 
 or not a tenderness at any point exists. Note where crests 
 would meet if extended. They normally meet, if extended, in 
 the median line about half way between pubes and knees. If 
 they meet to one side a lesion is usually the cause, it being a 
 slight twist or rotation of one innominate or in some cases a 
 twist of the pelvis on the fifth lumbar vertebra. Compare the 
 muscles attached just below the crest; perhaps one side is full, 
 the other shrunken. The full side is more often the diseased one. 
 
 Examine the symphysis pubis for irregularities or tender- 
 ness, either one indicating a displaced innominate. Turn the 
 patient on her side and examine the lumbar region and especially 
 the lumbo-sacral articulation for displacements and tenderness. 
 I rely a great deal upon the location of the tender spots, they 
 indicating something abnormal; if in a joint, a displacement; if 
 in a muscle, an abnormal contraction or contracture. This is 
 especially true in acute cases and the location of the tenderness 
 is indicative of the organ affected. In chronic cases soreness does 
 not always exist when there is a displacement, hence its ab- 
 sence does not necessarily negate a lesion, but in acute cases it 
 always exists and furnishes the best means for diagnosis. 
 
 In connection with the examination of the pelvis, palpate 
 the lower ribs, note their obliquity, the intercostal spaces and 
 points of tenderness, their displacement often causing ovarian 
 or kidney disturbances of some sort. Hystero-epilepsy some- 
 times results from lesions of these ribs. In palpating the ribs.
 
 METHOD OF EXAMINATION. 139 
 
 it is best to do it while the patient is sitting. The operator, sit 
 ting or standing behind the patient, places the hands on the 
 lower ribs and compares the two sides at the same time; devia- 
 tions being more readily found in this way.
 
 140 DISEASES OF WOMEN. 
 
 DISEASES OF THE VULVA. 
 
 VULVITIS. Vulvitis is defined as an inflammation of the 
 vulva, this comprising inflammation of the greater and lesser 
 lips, vestibule, clitoris, or any part of the external genitals. In 
 order to understand vulvitis it is necessary to know what inflam- 
 mation is, the changes taking place, symptoms and termina- 
 tion. 
 
 INFLAMMATION may be DEFINED as an EFFORT ON THE PART 
 
 OF THE ORGANISM TO RID ITSELF OF SOME TOXIC ELEMENT, or 
 
 overcome an injury. This toxic element may be introduced from 
 without, such as IRRITATING DISCHARGES or gonorrheal poison- 
 ing; or it may arise from within from stagnated blood, which has 
 undergone certain changes. There is congestion, arterial if 
 acute, venous if chronic, which gives rise to HEAT, REDNESS, 
 SWELLING, PAIN and disturbance of function, if the inflamma- 
 tion is a typical one. 
 
 In treating inflammation it is necessary to know which of 
 these causes are operating, since upon this depends the cure. 
 
 There are various forms of inflammation of the vulva, they 
 being classified according to their severity, and usually divided 
 into simple, gonorrheal, follicular and phlegmonous. In the 
 simplest form we find the catarrhal inflammation, while in cases 
 in which there exists a great deal of toxic matter, it is called the 
 phlegmonous type. 
 
 The cause of vulvitis may depend upon lack of cleanliness, col- 
 lection of dirt or smegma; the patient not cleansing herself properly
 
 DISEASES OF THE VULVA. 141 
 
 after menstruation. This foreign or toxic matter gets into the 
 folds of the vulva, first causing irritation and finally resulting 
 in inflammation. More or less exfoliation of the epithelium 
 takes place, leaving the parts raw, while patches of erosion and 
 ulceration occasionally occur. In obese people, the FRICTION 
 of the vulva produced by walking, especially in warm weather, 
 tends to irritate the parts, leaving them in an inflamed state. 
 
 Irritating or toxic discharges such as a chronic leucorrhea, 
 a cancerous, gonorrheal, acid vaginal or uterine secretion, and 
 INCONTINENCE of urine are common causes of vulvitis. The 
 source of most of these discharges is a diseased uterus or vagina. 
 Endometritis, ulceration of the cervix, or even simple conges- 
 tion or catarrh of the above organs produce it. Diabetes and 
 acid urine set up a pruritus which often terminates in an inflam- 
 mation of the vulva. In children the oxyuris or thread worm 
 may migrate from the rectum, setting up a pruritus which re- 
 sults in the patient scratching the part in her efforts to obtain 
 relief, leaving it red and swollen. From this results chronic 
 pruritus vulvae, or itching of the vulva. Traumatism, such as 
 falls astride a sharp object, blows, rape and awkward coitus, pro- 
 duce vulvitis. On account of the character of the tissues com- 
 posing the vulva, VULVITIS FROM TRAUMA is hard to cure. In 
 one case treated by the author AN ABSCESS DEVELOPED within 
 a few days from a bruise received from a fall on the sharp corner 
 of a chair. 
 
 GONORRHEA is given as a cause of vulvitis in TWO-THIRDS 
 of all cases. This per cent, is high, but not too fcigh for the 
 LOWER CLASSES of people, in which this disease is OFTENEST 
 found. The disease in such people is not properly treated and 
 parts not kept clean. On account of this and the character of 
 secretions, the labia are red and inflamed during the entire course
 
 142 DISEASES OF WOMEN. 
 
 of the disease. This form of vulvitis is discussed under the head 
 of specific vaginitis. 
 
 Sometimes PREGNANCY produces a swelling of the vulva 
 accompanied by a severe itching, which in turn sets up an inflam- 
 mation, but this is unusual. In PARTURITION, occasionally the 
 vulva is bruised resulting in inflammation, especially in cases 
 in which the external genitals are very small or if instruments 
 are used. 
 
 Vulvitis due to friction in walking involves the greater lips; 
 from masturbation, the lesser lips, clitoris and vestibule; from 
 rape or awkward coitus, the hymen, lesser lips, urethra and an- 
 terior vaginal walls; from trauma, the greater lips; and from 
 irritants, the OSTIUM VAGINAE and nymphae. LESIONS found 
 as a cause of most cases of vulvitis not specific, are usually a slipped 
 innominate or a subluxated lumbar vertebra; these affecting the 
 vaso-motor nerve supply to the part. The vaso-motor nerves 
 are derived indirectly from the hypogastric plexus and follow 
 the blood vessels to the vulva. This plexus is in relation with 
 the sacro-iliac synchondrosis and is affected whenever the in- 
 nominates are forced out of place, even though it be slight. If 
 the case is not one of traumatic or specific origin the cause should 
 be sought elsewhere than in the vulva itself. A uterine dis- 
 placement results in an abnormal acrid discharge and still back 
 of this is the primary cause, the disturbance of the bony frame- 
 work which encloses the pelvic viscera. 
 
 The MENOPAUSE is often accompanied by a "breaking out" 
 on the vulva. This eruption causes an itching which is the only 
 noticeable symptom in most cases. 
 
 The symptoms of vulvitis are those of inflammation; that 
 is, heat, redness, swelling, pain and disturbance of function; 
 the severity of the symptoms depending on the degree of the
 
 DISEASES OF THE VULVA. 143 
 
 disease. In ACUTE types there is marked heat, the parts are very 
 red and angry in appearance and the pain is constant. In the 
 MILDER cases heat is less noticed, the parts are only slightly red 
 dened and pain occurs at irregular intervals. On account of 
 the congested condition, there is a hypersecretion of mucus, 
 which in children is often of a sticky nature and tends to the 
 formation of adhesions, such as an acquired hooding of the cli- 
 toris. In other cases pus is discharged, but this occurs to an ap 
 preciable extent only in the very marked cases, such as the 
 phlegmonous type. In simple cases the discharge is serous or 
 muco-purulent and is USUALLY ABUNDANT, the amount being 
 determined by the degree of congestion. If it is purulent, vari- 
 ous micro-organisms can be found, their presence being a result 
 rather than a cause of the disease. It is accompanied by a 
 certain amount of pruritus of the vulva, especially when the 
 inflammation begins to recede and the secretions to dessicate. 
 Often the habit of masturbation is contracted in relieving the 
 itching, which habit when so formed is very hard to overcome. 
 On the other hand masturbation may cause vulvitis. Mont- 
 gomery says: "The production of vulvitis in the virgin by mas- 
 turbation is recognized by finding the smaller labium and the 
 space between it and the hymen covered with small pointed 
 excrescences ; the nymphae elongated ; the clitoris or its prepuce 
 irritated; swelling of the shallow groove between the orifice of 
 the urethra and the clitoris; clear, abundant secretion from the 
 duct of Bartholin's glands; abnormal sensibility; exaggerated 
 prudery; and distinct hysterical phenomena." 
 
 Sometimes there is EDEMA of the vulva in cases of vulvitis, 
 especially if it depends upon pregnancy as the cause. MICTURITION 
 is interfered with, it usually being frequent, painful and im- 
 perfect, or the inflammation in its early stages may ENTIRELY
 
 144 DISEASES OF WOMEN. 
 
 OCCLUDE THE URETHRAL orifice, resulting in the retention of the 
 urine. The neighboring glands, Bartholin's in particular, are 
 swollen, congested and a hypersecretion is fairly constant. In 
 the follicular type the hair bulbs and sebaceous glands are swollen, 
 these being the seat of the disease. The tissue between these 
 hair follicles and glands is apparently healthful, thus giving the 
 diseased area a mottled appearance. These follicles continue 
 to increase in size until they burst, after which they soon shrivel 
 and dry up. During the period in which the enlargement of 
 the follicle is greatest, a drop of pus can be expelled by pressure 
 on it. 
 
 The treatment depends upon the CAUSE that is found in the 
 individual case. If the inflammation is severe, some emollient 
 application should be used merely as a palliative agency to re- 
 lieve the heat and burning. The part should be KEPT CLEAN 
 and should be washed with some mild antiseptic solution such 
 as boracic acid solution. If there are bony displacements which 
 are to blame for the trouble, they should be treated. The blood 
 supply should be controlled, if possible, this being done to a 
 certain extent by treatment applied to the lower lumbar region. 
 If there is a mechanical obstruction to the venous return, such 
 as a displaced uterus or prolapsed bowels, this should be cor- 
 rected. When pregnancy is the cause a cure is not probable 
 until after parturition. If the inflammation is of venereal ori- 
 gin, the application of a rose colored solution of PERMANGANATE 
 OF POTASSIUM is beneficial, sometimes even destroying the gon- 
 orrheal germs, it being a germicide. If it is a very bad form of 
 inflammation, the patient should be kept as quiet as possible 
 to prevent friction and irritation of the part, this coupled with 
 the correction of the various lesions found, has yielded nice re- 
 sults in the author's practice.
 
 DISEASES OF THE VULVA. 145 
 
 DISEASE OF BARTHOLIN'S GLANDS. Diseases of Bar- 
 tholin's glands, especially, those not inflammatory in character, 
 are seldom seen before the age of seventeen or after the age of 
 forty-five, the disturbances therefore occurring during the years 
 in which the SEXUAL FUNCTION is MOST ACTIVE. Their CAUSES 
 depend upon incidents connected with the SEXUAL FUNCTIONS 
 such as excessive or violent intercourse, masturbation or ac- 
 cidents of pregnancy or labor. 
 
 The INFLAMMATORY disturbances of these glands are seldom 
 primary, but occur as complications of vulvitis or vaginitis, 
 especially the gonorrheal variety. In cases in which the glands 
 are temporarily enlarged from congestion, there is a hypersecre- 
 tion of a glairy fluid and is one of the sources of the discharge 
 in leucorrhea. Their FUNCTION is to secrete a mucus which 
 lubricates the external genitals ; this is most marked during sexual 
 excitement. There is no emission in the female, only a hyper- 
 secretion, this coming principally from Bartholin's glands. 
 Sometimes erotic dreams cause this hypersecretion, especially 
 if the glands are congested and irritable. By placing the finger 
 over the duct and pressing up and back, the enlarged gland can 
 be felt; the causes which produce hypersecretion leading also to 
 its enlargement. The ORIFICE of the duct, which is located on 
 the inner posterior aspect of the middle portion of the lesser lip, 
 is surrounded by a red areola, giving it the appearance of the 
 bite of an insect. 
 
 Affections of Bartholin's glands interfere with sexual inter- 
 course since the discharge, or rather hypersecretion, comes from 
 these glands and in cases of LOSS of sexual desire these glands 
 are usually atrophied. When there is increased sexual desire, 
 the glands are large and irritable, even psychic influences causing 
 
 a discharge of mucus. It is the analogue of Cowper's gland in 
 10
 
 146 DISEASES OF WOMEN. 
 
 the male, its function being similar, that is, it secretes a lubri- 
 cant. In cases in which tonicity of the vaginal walls and vulva, 
 is lost, Bartholin's glands are usually found to be diseased and 
 leucorrhea forms one of the symptoms. One has said that a 
 flabby, pendulous condition of the abdomen results from affec- 
 tions of Bartholin's glands. 
 
 In difficult labor dependent upon a rigid cervix and vagina 
 the "Old Doctor" has advised INHIBITION OF THESE GLANDS, 
 this helping dilatation of the os UTERI AND VAGINA. 
 
 When the DUCT is OCCLUDED it causes retention of the secre- 
 tion, thus forming a cyst. This is diagnosed from hernia by its 
 position, shape, size and fluctuation. Often an ENLARGEMENT 
 of this gland, varying in size from that of an ordinary marble 
 to that of an orange, results from a STRAIN OR SLIP OF THE INNOM- 
 INATE bone on the same side. The author has treated several 
 cases of this sort, the swelling coming on within a few hours 
 after the accident. Sexual intercourse aggravates the trouble 
 and usually by the time the patient consults a physician, the 
 swelling is considerable. The correction of the innominate 
 lesion is sufficient in such cases to effect a cure. The accident 
 results from a twist of the body or a fall, the patient slipping on 
 an icy pavement, or due to strain resulting from the attempt to 
 recover. 
 
 Abscesses sometimes form in this gland and should be treated 
 according to the rules of surgery. In the treatment of the dis- 
 eases affecting this gland, remove the sources of irritation and 
 direct the work to remove obstructions to the venous drainage 
 in order to relieve the congestion. There should be complete 
 rest of the gland, sexual intercourse being forbidden. Fre- 
 quently uterine or vaginal troubles, such as loss of tonicity, are 
 the primary causes and in such cases the treatment should be
 
 DISEASES OF THE VULVA. 
 
 147 
 
 directed to those organs. Manipulation over and around the 
 gland is beneficial and especially so in cases of congestion. Cysts 
 of this gland can be reduced by opening up the duct with a probe 
 or by direct manipulation over the part, by which the contents 
 
 FIG 56. Detention of the right vulvo-vtigiiml gland 
 with pus. (By ford). 
 
 of the cyst are forcibly expelled. 
 
 PRURITUS VULVAE. This affection consists of an irrita- 
 bility of the nerves supplying the vulva which gives rise to an 
 INTENSE ITCHING and burning of the part. The REGIONS AFFECT- 
 ED are the inner side of the LABI A MAJORA, the LABI A MINORA
 
 148 DISEASES OF WOMEN. 
 
 and the CLITORIS. In some cases it may extend to the mons 
 Veneris, anus and the inner sides of the thighs. It is not a dis- 
 ease but a symptom, hence the curative treatment should not 
 be directed entirely to the parts affected, but to the cause. This 
 irritation is either at the peripheral or spinal end of the nerve, 
 that is, a local irritation or a referred impulse. 
 
 The irritation at the spinal end is the result of an impinge- 
 ment or disturbance of nutrition of the deep origin of the nerve, 
 in other words is due to a bony lesion pressing on the nerve at its 
 exit, or along its course, or on the blood vessels supplying the 
 nerve or its cells with nutrition. 
 
 Another cause of this affection is dirt or the accumulation 
 of smegma after menstruation, and sometimes the disease is 
 due to the oxyuris or threadworm which has migrated from the 
 rectum to the vulva. PEDICULI pubis form an important cause 
 in the lower classes. The "crabs", as they are commonly called, 
 burrow deeply in the mons Veneris, thereby setting up a severe 
 pruritus, or in some cases, a well developed inflammation, if 
 the patient scratches the part very violently, as is often the case. 
 Sometimes pessaries are the cause, especially if they are ill fitted; 
 they irritate the vaginal wall and cause a perverted or a markedly 
 acid secretion. In vulvitis, especially during the healing state,, 
 there exists a certain amount of itching, this indicating that the 
 part is healing. Diabetes, a very important cause, results in 
 pruritus on account of the irritating material found in the urine 
 which is deposited around the meatus and in the vestibule, giving 
 rise to a local irritation. Any form of irritating deposit in the 
 urine or an acid condition of the urine, as found in acute rheuma- 
 tism, may cause the itching. Abnormal discharges from the 
 vagina, such as leucorrhea, is a common cause, especially if it is a 
 chronic form and the secretion has partly desiccated. The dis-
 
 DISEASES OF THE VULVA. 149 
 
 charges from a cancerous condition will also produce irritation 
 which gives rise to itching. 
 
 Frequently at the menstrual time or immediately before or 
 after it, the patient will complain of itching of the vulva, and 
 in some cases it is almost unbearable. The writer had a case re- 
 cently of this kind which could only be relieved by a vaginal 
 douche as hot as could be borne. Congestion of the vulva will 
 usually give rise to the itching, this congestion frequently being 
 the result of pregnancy. Itching often accompanies the meno- 
 pause, or even old age, giving rise to various nervous symptoms. 
 Reflexly it may result from intestinal irritation, diseases of the 
 rectum, such as hemorrhoids, diseases of the uterus with its 
 appendages and the urethra. To the osteopath the lesions found 
 in the region of the fifth lumbar are the most important. Also 
 lesions found at the junction of the sacrum with the ilium, that 
 is, subluxations of the sacrum or innominate, disturb the nutri- 
 tion of the parts, thus setting up a disturbance in the sacral 
 nerves. 
 
 The pathology of the disease is practically unknown. One 
 observer mentions that many of the nerves, when traced from 
 the deeper parts toward their termination, were seen to acquire 
 a dense, fibrous character, some appearing as well marked fibrous 
 cords, the nerve fibers being compressed or destroyed. This 
 applies only to the chronic cases. 
 
 This trouble is SIMILAR TO PRURITUS ANI or itching piles; 
 the two are sometimes found in the same subject, the lesions 
 being almost the same in the two affections. In the beginning 
 the irritability is very slight and annoys the patient very little, 
 sometimes existing only after exertion in warm weather, upon 
 exposure to artificial heat or during menstruation. The rubbing 
 or scratching of the part aggravates the trouble rendering the
 
 150 DISEASES OF WOMEN. 
 
 skin tender and the nerves more sensitive. As the disease pro 
 gresses the irritation increases, the patient is bereft of sleep at 
 night, avoids society and becomes melancholic; sometimes the 
 affection even terminating in insanity. On account of loss of 
 sleep, the nervous system is affected, nervous prostration some- 
 times ensuing. In children, masturbation frequently follows, 
 which habit in the young is hard to break. In adults it leads to 
 frequent coitus, even rendering the patient hysterical or nympho- 
 maniacal. On palpation, tenderness is found at the fifth lumbar 
 sometimes radiating over the hip bones. 
 
 In TREATING this affection,it is necessary to find the primary 
 cause of the disorder. If due to external irritation, such as an 
 accumulation of filth, leucorrhea, acrid discharges or parasites, 
 remove the source of irritation by thoroughly cleansing the parts. 
 In case of pediculi pubis, or lice, which are lodged in the mons 
 Veneris, thoroughly anointing the affected area with mercurial 
 or sulphur ointment is sufficient to cause the death of the para- 
 site. As a rule, in the ordinary cases of pruritus, local applica- 
 tions do very little good because they do not reach the cause of 
 the trouble. In some such cases, as those due to discharges, 
 applications are of value. The best applications in the author's 
 hands are carbolic acid, witch hazel and plain hot water or hot 
 compresses. A weak carbolized solution is probably the best of 
 all. In cases due to pin worms a rectal injection of lime water 
 is good. The "Old Doctor" has advised the application of an 
 ointment of lard and turpentine in such cases. The diet is im- 
 portant in cases due to liver or kidney diseases. Alcohol 
 and spiced food should be excluded. Treatment over the sacrum 
 and fifth lumbar, correcting such lesions as are found, is the most 
 satisfactory method of dealing with this trouble in cases in 
 which the pruritus is not due to local changes or causes.
 
 DISEASES OF THE VULVA. 151 
 
 KRAUROSIS VULVAE is a term applied to the condition 
 in which the lesser lips are atrophied, Avith hardening of the mucous 
 membrane and skin of the vulva. At first the parts are inflamed 
 in appearance, there being small red spots or streaks of dilated 
 arterioles which radiate from the center of the nymphae. These 
 disappear as the disease progresses and atrophy advances. There 
 is loss of sexual desire ; whether the cause or result of the atrophy, 
 is unknown. 
 
 The cause of this condition is unknown, not even a good 
 theoretical explanation being offered by the medical authori- 
 ties. The writer has seen only a limited number of cases. In 
 all of them there was a very rigid lumbar spine with muscular 
 contractures. In some of these cases an innominate lesion was 
 discovered. 
 
 Pruritus is one of the most constant symptoms, along with a 
 dry condition of the parts, with a tendency to crack and bleed 
 on coitus or digital examination. 
 
 In the cases treated by the author, work was directed to the 
 innominate and lumbar lesions. The cases were benefited and 
 one case almost entirely cured. 
 
 VARICOSE VEINS OF THE VULVA. A VARICOSE VEIN is 
 one that has been distended to an extent or for such a length of 
 time, that a part or all of the elasticity of the walls has been 
 destroyed. The distention is due to obstruction of the venous 
 return or a paresis of the muscle fibers in the walls of the veins. 
 In case of varicose veins of the vulva, the engorgement is due to 
 obstruction of the veins draining the vulva, this obstruction 
 usually being caused by pregnancy. The parts affected are the 
 bulbs of the vagina and the labia majora. Sometimes these 
 bulbs are enlarged and can be readily felt on palpation. This 
 gives rise to a swelling of the vulva attended by a hypersecretion.
 
 152 DISEASES OF WOMEN. 
 
 The treatment consists of removing the obstruction and if 
 due to pregnancy, little can be done until after parturition. If 
 due to enteroptosis, the intestines should be drawn upward, 
 allowing the blood to drain from the vulva. Often rectal and 
 uterine congestion so obstruct the blood that the veins of the 
 vulva become varicosed, since there is a very free anastomosis 
 of all these veins. Strong treatment in the back frequently helps 
 the condition by strengthening the vaso-motor supply to the 
 part. 
 
 There are VARIOUS OTHER AFFECTIONS OF the vulva, but 
 only their names will be given on account of their scarcity. The 
 writer saw a case of ATROPHY of the greater lips accompanied 
 by hypertrophy of the lesser in a subject which was the victim 
 of masturbation. ELEPHANTIASIS is found in tropical countries 
 but is rare in this country. Tumors, such as a fibroma, lipoma 
 and rarely carcinoma, have been found affecting the vulva. 
 
 Once in a while a condition called a HOODED CLITORIS is found, 
 and is the cause of various nervous troubles such as chorea or 
 epilepsy and other forms of spasms. This hooded condition may 
 be the result of non-development, but is usually in the adult, the 
 result of adhesions which bind the glans down. The labia 
 majora divide at their anterior or superior extremities, the part 
 or fold above the clitoris forming its prepuce, and the part below, 
 its frenulum. Sometimes these parts adhere, thus encapsulat- 
 ing the glans clitoridis. In other cases the lips do not separate, 
 hence the congenital type of hooded clitoris. In either case it 
 is a source of irritation and is the cause of various reflex troubles. 
 To illustrate this: I saw a case in which there was spasmodic 
 twitching of the limbs which came on daily, due to adhesions of 
 the clitoris, which on being removed gave immediate relief. In 
 cases resulting from inflammation, the adhesions can be broken
 
 DISEASES OF THE VULVA. 153 
 
 manually. In congenital cases a slit in the membrane covering 
 the glans has to be made, thereby exposing and freeing it. 
 
 Diseases of the meatus are comparatively rare. URETHRAL 
 caruncles are occasionally found. They are vascular tumors or 
 angiomata of the urethra at or near the meatus urinarius. The 
 diagnosis is easily made by inspection. The growth consist of 
 a bright red excresence, in shape like a strawberry or red rasp- 
 berry, springing from the side of the meatus. They vary as to 
 size; the largest seen by the author was about the size of a small 
 marble. 
 
 The cause is not well understood, injury being the most 
 common. The injury is to the urethra, by which the blood, 
 vessels are directly bruised and results from the awkward use of 
 instruments or from a fall on the part. 
 
 The chief and almost constant symptom is, painful and 
 frequent micturition. Intercourse is very painful or impossi- 
 ble; locomotion is difficult on account of the pain in the parts 
 whenever jarred or moved. At or near the menstrual period the 
 enlargement is greatest and most sensitive, hence the above 
 symptoms are exaggerated at this time, and in some cases the 
 patient can seldom find an easy posture. In chronic urethritis, 
 the mucous membrane may become everted, thus giving rise to 
 symptoms similar to those from a caruncle. 
 
 The usual treatment is removal, either by a caustic or the 
 knife. This is not always successful as a cure, since it may re- 
 turn. In some cases it can be absorbed, in others the tumor 
 will remain but loses its fiery red color, after which the sensi- 
 tiveness diminishes. 
 
 The vulva is often the seat of injuries. The patient may 
 fall astride a chair or other object, this occurring in servants 
 engaged in cleaning windows; or in bicyclists who are thrown
 
 154 DISEASES OF WOMEN. 
 
 forward on the iron frame of the wheel. Children while at play 
 may fall astride a picket fence or be injured by sliding down an 
 incline. In such cases as the above, the blood vessels are caught 
 against the pubic bone and often severed, the escape of blood in 
 such cases forming a hematocele. The hemorrhage is very copi- 
 ous on account of the abundant anastomosis of these veins and 
 arteries. 
 
 Parturition sometimes causes an injury to the vulva, especi- 
 ally if the case is not properly cared for. Reed says: "Con- 
 tusions of the labia and sometimes of the vulvo-vaginal glands 
 are due in the majority of instances, to a failure of the head to 
 rotate into the conjugate diameter of the outlet of the pelvis. 
 Not infrequently does the careless use of forceps cause lacera- 
 tion of these parts." Complete rotation should be obtained before 
 extension is well under way. This is secured by local manipula- 
 tion when labor pain is on. 
 
 VAGINITIS. Vaginitis or colpitis is an inflammation of the 
 mucous membrane of the vagina. The mucous lining of the 
 vagina resembles very closely in structure that of the skin, hav- 
 ing few, if any, submucous glands. The vaginal secretion is 
 acid, and is germicidal in action, during health. During the 
 menstrual period, the puerperium and in case of leucorrhea, the 
 discharge is faintly acid or alkaline a condition favorable to 
 the growth of micro-organisms. Stroganoff claims that the 
 vagina of the new born is free from micro-organisms but that 
 " baths, washings and especially the application of oleaginous 
 substances favor the entrance of germs." Even if they do enter 
 they are harmless until the vitality of the part is lowered from 
 other causes. Kronig asserts that "all secretions alike contain 
 no pathogenic germs. All secretions are equally germicidal, 
 though the vitality of the germs differs. It takes twice the
 
 DISEASES OF THE VULVA. 155 
 
 time to kill the staphylococcus that it does to destroy the strep- 
 tococcus." 
 
 According to the investigations of many, the normal vaginal 
 secretion is of a whitish, crumbling material of the consistency 
 and appearance of curded milk, containing little mucus and 
 giving an intensely acid reaction. The pathological secretion, on 
 the other hand, is of a yellowish or greenish yellow color, cream 
 like in consistency and weakly acid or neutral. The VAGINA 
 infected with pyogenic micro-organisms will become ASEPTIC 
 in from a few hours to tw r o or three days. Any injection or 
 douche which dilutes or washes away the normal vaginal secre- 
 tion lessens the germicidal action. This is proven by the in- 
 vestigation of various writers. In a series of experiments Kronig 
 found that a solution of corrosive sublimate for irrigation de- 
 stroys the germicidal action, probably by precipitation of the 
 albumen, while plain water but lessens it. 
 
 Experiments have been made by taking three normal sub- 
 jects and introducing pathogenic micro-organisms into the 
 vagina. In one case NO INJECTIONS were used immediately be- 
 fore the introduction of the germs, and the vagina rid itself of 
 the micro-organisms within a few hours. In the second, a thor- 
 ough PREPARATORY plain water vaginal DOUCHE was given; as 
 a result it took several days for the vagina to rid itself of the 
 bacteria. In the third case an ANTISEPTIC DOUCHE was given 
 just before the germs were introduced into the vagina with the 
 result that it did not entirely free itself of them before the fourth 
 day. From this it is necessary to infer that injections of cor- 
 rosive sublimate or water are prejudicial. Menje, in his investi- 
 gations on the nonpuerperal women, introduced pyogenic organ- 
 isms into the vagina in eight patients and found that the vagina 
 cleansed itself from these organisms in periods varying from two
 
 156 DISEASES OF WOMEN. 
 
 and one-half hours to three days. I quote these statements be- 
 cause they illustrate the osteopathic theory that a healthy mucous 
 MEMBRANE is SELF-CLEANSING, its SECRETIONS germicidal, and 
 that WASHES IMPAIR ITS VITALITY. I have had a number of 
 cases which conclusively proved to me that the above statements 
 are true. 
 
 The liquor amnii is another antiseptic fluid designed by 
 nature to protect the internal organs. After delivery of a child 
 in which the fingers were covered with this fluid, I have noticed 
 that they were wrinkled and the skin drawn up. This is not due 
 entirely to the amniotic fluid but to the vaginal secretions. I 
 mention this to prove how complete the body is in resources to 
 protect itself, and to show that disease, especially vaginitis, usual- 
 ly comes from external causes, and that pyogenic bacteria are 
 introduced by instruments or douches. Another idea has re- 
 cently been advanced relative to the germicidal action of the 
 vagina. Gilliam (p. 110) says: "The vagina and those portions 
 of the genital tract above the vagina are still further safeguarded 
 by a germ which inhabits the canal, which is not pathogenic and 
 which produces an acid secretion which is inimical to other germs. 
 This is known as the acid secreting germ of Doderlien." This 
 germ, if acting normally, prevents the existence, or at least the 
 multiplication, of pathogenic germs in the genital tract. The 
 gonococcus of Neiser is perhaps an exception, yet the writer believes 
 it to be harmless when deposited on a healthy mucous mem- 
 brane. The above facts alone would negate vaginal douches, 
 since such wash away those helpful germs, thus weakening the 
 natural defenses. 
 
 The VARIETIES of vaginitis depend on degree of inflamma- 
 tion, usually it is divided into the SIMPLE and the SPECIFIC. 
 This classification into the simple and specific vaginitis depends
 
 DISEASES OF THE VULVA. 157 
 
 upon whether the toxic elements arise from within or are intro- 
 duced from without. Simple vaginitis depends upon some toxic 
 element which has been produced by the changes which have 
 taken place in the stagnated blood. BLOOD, in order to be PURE, 
 must be MOVING, and if the rapidity is lessened vitality is lowered, 
 and if the flow is entirely stopped, fermentation and putrefaction 
 follow. In the specific form the toxic element is introduced from 
 without, the gonorrheal form being the most common type. 
 
 THE CAUSES of simple vaginitis are INJURIES to the walls 
 by means of some instrument, as in an attempted abortion, ex- 
 cessive or awkward coitus, irritating discharges, injections too 
 cold or containing injurious chemical agents, caustics, decompos- 
 ing compounds, and tampons or pessaries that have been left in 
 in the vagina for some time. Herman says that puerperal vagi- 
 nitis, that is the form due to injury of the vaginal walls at labor, 
 is the most common type. The vagina is often bruised, scraped 
 or even lacerated in some instances, and quite often too, in prim- 
 ipara, if care and caution are not used. 
 
 Any LESION affecting the vaso-motor center will cause con- 
 gestion, and unless corrected, will terminate in inflammation. 
 The most common lesion is at the lumbo-sacral articulation or at 
 the sacro-iliac synchondrosis. I saw a case recently in which 
 the lesion was at the fourth and fifth lumbar, but usually in those 
 cases an endometritis complicates the vaginitis. In many of these 
 cases the lesions are higher, that is in the upper lumbar region, 
 and primarily affect the uterus, which in turn produces vaginitis 
 on account of the irritating discharges. In inflammation of the 
 cervix uteri, the disease may travel by continuity of tissue to the 
 vaginal walls and there set up a secondary inflammation. 
 
 DISPLACEMENTS, CONGESTION and INFLAMMATION of the 
 uterus produce vaginitis by interfering with the venous return
 
 158 DISEASES OF WOMEN. 
 
 from the vagina. Some of the worst cases the writer has 
 ever treated followed uterine inflammation which resulted from 
 a hard labor in which the cervix was lacerated. As mentioned 
 above, the intensely acrid discharge erodes the surface of any 
 part with which it comes in contact. The writer has seen 
 cases in which the discharge was so strong that the integument of 
 the INNER SIDES OF THE THIGHS was ERODED at the points at 
 which some of the discharge accidentally came in contact. In 
 other cases a deposit of thick, creamy, leucorrheal discharge part- 
 ly or completely filling thefornices, sets up an irritation sufficient- 
 to excite inflammation. Subinvolution of the vaginal walls 
 following childbirth is often the cause of a chronic form of vagi- 
 nitis, since the vaginal walls as well as the uterus involute after 
 delivery, and in subinvolution of one, the other is affected. 
 
 The SPECIFIC form is caused by GONORRHEAL infection. It 
 is hard to cure on account of its tendency to spread to the uterus 
 and Fallopian tubes and there set up a chronic inflammation. 
 
 The important pathological point is CONGESTION. The blood 
 vessels are engorged, the surface red and painful, and in the worst 
 cases permanent degenerative changes take place, such as a 
 deposit of scar tissue in the walls of the vagina. 
 
 The CLINICAL SYMPTOMS of vaginitis do not differ very much 
 in the various types of inflammation except that in the specific 
 type they are more intense. There is HEAT, sense of DRYNESS at 
 first, and burning of the vagina. This extends to the urethra, 
 causing FREQUENT, IMPERFECT and BURNING micturit ; on. At 
 first there is little or no secretion, but in a few days there is a 
 leucorrheal discharge of an offensive odor. Pains of a throbbing 
 character are referred to the PELVIS and GROINS. There is red- 
 ness and excoriation of the vaginal opening. The LABIA ARE 
 SWOLLEN, red and irritable; vaginal examination causes great
 
 DISEASES OF THE VULVA. 159 
 
 pain and often cannot be tolerated. The INGUINAL LYMPHATIC 
 GLANDS are frequently TENDER and ENLARGED, their function 
 being to collect the toxic elements resulting from the inflamma- 
 tion and prevent them from being thrown into the general cir- 
 culation. In acute cases the usual malaise, anorexia and fever 
 are found. 
 
 The above symptoms vary with the degree of inflammation; 
 they being lessened, or some of them absent in the simple form, 
 while in the aggravated form they are exaggerated. 
 
 The symptoms of the specific form of vaginitis, are similar 
 to those of the simple form, but are more intense. The 
 disease is not confined to the vaginal walls but extends to 
 the urethra. In fact, the meatus seems to be the seat of the dis- 
 ease in that the inflammation is greatest at that point. Traces 
 of the disease remain for quite a while, after an apparent cure. 
 The parts are in the beginning very tense, red, hot and dry, but 
 after a few days a muco-purulent discharge appears. Its diag- 
 nosis depends upon the discovery of the presence of the gonococ- 
 cus of Neiser. which is ascertained by microscopical examina- 
 tion. 
 
 In making a microscopic preparation, obtain the secretion, 
 spread in a thin film on a clean glass slide ; allow to dry in the air 
 then pass it through the flame of an alcohol lamp two or three 
 times, being careful to have the pus side turned up. A drop or 
 two of dilute water solution of one of the analine dyes, methyl 
 blue being commonly used, is then applied by a glass rod, and left 
 on for two or three minutes. The specimen should then be care- 
 fully dried, mounted in Canada balsam and studied with a high 
 power oil immerison lens. The gonococcus may be recognize .1 
 by the following description : They occur in pairs or in groups of 
 four, but generally in the form of diplococc 1 '. According to
 
 160 DISEASES OF WOMEN. 
 
 Steinberg, the flattened surfaces face each other and are only 
 separated in stained preparations by a small unstained interspace. 
 They have aptly been compared in shape to " BISCUITS" with 
 the FLAT SURFACES IN APPOSITION. In chronic cases, the micro- 
 organisms are embedded in the epithelial cells. When a pa- 
 tient comes to you suffering with some form of vaginitis, be 
 careful as to the diagnosis you make and DO NOT MISTAKE a SIM- 
 PLE VAGINITIS for a SPECIFIC, since the patient's social happiness 
 may depend upon your diagnosis. 
 
 The adhesive type of vaginitis is found in cases of, or rather 
 follows, marked inflammation in old women and sometimes in 
 young girls. The fornices grow fast to the cervix; sometimes 
 they are entirely obliterated and the vaginal lumen partly or 
 completely obstructed. 
 
 The prognosis in the simple form of vaginitis is good. In 
 the specific type there is grave danger of the disease reaching 
 the uterus, tubes and ovaries. In such cases a cure is the excep- 
 tion, especially in cases of a year or more duration. Since the 
 prognosis depends on limiting the diseased area, care should be 
 taken in the giving of injections as the micro-organisms may be 
 carried higher, even into the uterus. 
 
 Treatment consists in first removing the noxious elements 
 or toxic material, and second, restoring normal circulation. If 
 there is any irritating discharge treat the source of that discharge. 
 If a lesion is found, whether bony as in the lumbar region, or a 
 displaced uterus, correct the disturbance. In short, TREAT ANY 
 ABNORMALITY which may affect the vaso-motor supply of the 
 vagina or interfere with the venous return. Since the VEINS 
 DRAINING the VAGINA DRAIN THE UTERUS, it follows that uterine 
 disease, especially displacement, will cause congestion of the 
 vagina, thus predisposing it to inflammation and other diseases.
 
 DISEASES OF THE VULVA. 161 
 
 Washes and douches are usually prescribed but should be used 
 only for cleanliness sake, or as a palliative treatment. Local 
 treatment over the sacrum and stimulation over the lower lum- 
 bar region will help, also treatment over the abdomen to remove 
 the pressure exerted by the intestines. 
 
 If the inflammation is of specific origin, use as a wash a warm 
 rose colored solution of permanganate of potassium, three times 
 daily, until the microbes are destroyed, which is indicated by 
 cessation of the discharge of pus, this usually taking about a 
 week. The DRY TREATMENT is recommended in cases of specific 
 vaginitis, in which it can be substituted. The vaginal walls are 
 exposed by means of a Sims speculum, and then thoroughly 
 cleansed and wiped dry by a cotton swab saturated with some 
 antiseptic solution, such as bicloride of mercury or bismuth. As 
 a rule it is not policy for the osteopath to treat venereal diseases ; 
 he should rather refer such cases to the specialist. 
 
 VAGINISMUS. This affection consists of a peculiar HYPER- 
 ESTHESIA of the nerves of the mucous, membrane of the vagina,, 
 irritation of which produces a painful, spasmodic contraction of 
 the muscles surrounding the vagina or pelvic floor, resulting in 
 tightly closing the lumen of the vagina, PREVENTING or MAKING 
 DIFFICULT digital or instrumental EXAMINATION, or COITION. 
 It is quite a rare disease, found principally in young, nervous, 
 hysterical women who suffer from dysmenorrhea from flexion 
 of the uterus. It is not really a disease of the vagina with path- 
 ological changes as it is ordinarily understood, but only a nerv- 
 ous condition dependent on an irritation to the muscles of the 
 pelvic floor or to a general nervous irritability. 
 
 It is usually produced by some LOCAL IRRITATION, such as 
 a URETHRAL CARUNCLE or a DISEASED HYMEN, which, when 
 
 touched, causes pain and contraction. Sometimes the remains 
 n
 
 162 DISEASES OP WOMEN. 
 
 of the hymen continue to be irritable for some time after it 
 has been ruptured, they not having properly healed, this giving 
 rise to great pain during intercourse or an attempt to make a 
 vaginal examination. 
 
 A DISPLACED COCCYX is quite often the cause of vaginismus. 
 If the coccyx is displaced laterally or backward it puts on a ten- 
 sion the muscles attached to it; if thrown forward it produces 
 pressure on the posterior vaginal wall. If tenderness is pres- 
 ent at the sacro-coccygeal articulation, or at the tip of the bone, 
 the lesion is in all probability the cause of the disease. PELVIC 
 INFLAMMATION due to metritis or uterine displacement affects 
 the sacral .nerves by extension of the inflammatory process to 
 them; this in turn affects the muscles innervated by them, viz., 
 the muscles of the pelvic floor. A TENDER OVARY is often found 
 in cases of vaginismus which when touched, causes contraction 
 of the muscles of the pelvic floor. 
 
 If the patient's general nervous system is impaired the nerv- 
 ous form of vaginismus will be produced, there being no local 
 disturbances. The hyperesthesia is general, as is manifested by 
 the nervousness and general tenderness. In such cases spinal irrita- 
 tion is marked and the vertebrae separated on account of the 
 relaxation of the ligaments, thus producing hypermobility. 
 VAGiNiTisis a cause of this condition, since it produces contraction 
 of the sphincter muscle with great pain, when the tender vagi- 
 nal walls are irritated. LESIONS found in the lower lumbar re- 
 gion, affect the innervation to the vagina and if the lesion irri- 
 tates instead of inhibits the nerves, sacral and pudic, vaginismus 
 will result. 
 
 The symptoms are those of dyspareunia and spasmodic 
 contractions of the vaginal walls whenever an attempt is made 
 to give a local examination. As soon as the finger comes in con-
 
 DISEASES OF THE VULVA. 163 
 
 tact with the site of the hymen, the patient will complain of agon- 
 izing pain and become very much disturbed in her nervous sys- 
 tem. Should the examination be persisted in, the introduction 
 of the finger will be found almost impossible, and if forced into 
 the canal is tightly grasped by the sphincter muscle. 
 
 This affection, when chronic, gives rise to general nervous- 
 ness, irritability and spinal irritation, thus becoming a real, 
 distressing form of disease in addition to its local effects. 
 
 The PALLIATIVE treatment consists of strong inhibition of 
 the nerves supplying the vagina. This is best accomplished by 
 pressure applied to the posterior sacral region. This relaxes 
 and relieves but only for a short time. The cause must be re- 
 moved; that is, the lumbar and sacral lesions corrected. Often 
 the inhibitive treatment is given before attempting a local va- 
 ginal examination or treatment, and is usually helpful and ad- 
 visable. 
 
 RECTAL TENESMUS is a similar trouble and can be relieved 
 by a similar treatment. Vesical tenesmus can also be relieved by 
 inhibition of the nerves innervating the part. 
 
 Sometimes vaginismus is treated by DILATATION OF THE VA- 
 GINA either by a glass dilator or by means of the finger. By 
 doing this the contraction is forcibly overcome; this being a good 
 form of treatment only in a few cases. When instruments are 
 used for the purpose of dilatation of the vagina, the patient 
 should be anesthetized. PARTURITION is a cure for this condi- 
 tion; the only trouble is that pregnancy is usually precluded by 
 the disease. 
 
 Surgeons have devised operations for the cure of vaginismus. 
 The most important is Sims', by which the bulbo-cavernosi 
 muscles are severed. In cases of disease of the hymen in which 
 some of the carunculae myrtiformes are enlarged and tender,
 
 164 DISEASES OF WOMEN. 
 
 removal of these sensitive lumps is indicated, if the case does not 
 yield to the ordinary osteopathic treatment for same. By the 
 osteopathic method, the constrictor muscles are relaxed by in- 
 hibiting the nerves supplying them and physiological dilatation 
 results. 
 
 A case was reported to rne by Dr. Anna Hannah which de- 
 serves special notice. The patient was a married woman and 
 during the eight years of married life, intercourse was impossible 
 on account of the spasms or contractions of the vagina, they be- 
 ing so severe that the act was prohibited. Various treatments 
 had been resorted to, such as forcible dilatation under anesthesia, 
 the use and wearing of dilators, etc., but the patient did not im- 
 prove. Under anesthesia a digital vaginal examination could 
 easily be made showing no organic disturbance. Under osteo- 
 pathic treatment the case was entirely cured, the patient be- 
 coming pregnant and giving birth to a living child. The cure 
 was accomplished by correcting some lesions found in the lower 
 lumbar region, coupled with strong inhibition over the sacrum 
 and frequent attempts at giving local vaginal treatment. At 
 first these local treatments were decidedly incomplete in that only 
 a partial intromission was possible and that very painful. After 
 a few weeks the treatments were less painful ; the patient became 
 less nervous, her confidence having been won, and gradually the 
 irritability disappeared. 
 
 CYSTOCELE. Cystocele or vesico-vaginal hernia, consists 
 of a descent of the bladder so as to impinge upon the vaginal 
 canal and forcing the anterior wall downward into the lumen of 
 the vagina. It is really a prolapsus of the anterior vaginal wall 
 which is the principal support of the bladder. Either of the 
 vaginal walls may prolapse forming a bulging, softened tumor of 
 the part, such as rectocele, enterocele or cystocele, the last being 
 the most common.
 
 DISEASES OF THE VULVA. 165 
 
 Since the disease is seldom seen in nullipara, CHILDBIRTH is, 
 almost invariably, the cause of this condition, the vaginal canal 
 being so enormously distended in some cases that the tone of the 
 walls, in this case the anterior wall, is lost and the bladder pushes 
 it outward and downward. If the wall is also bruised in delivery, 
 it will be the more weakened and a heavy distended bladder may 
 cause a prolapsus of it. The bladder should be emptied soon 
 after parturition on account of its increased w r eight and the 
 weakness of its support. 
 
 LACERATION of the perineum weakens the vaginal walls, 
 hence may be the cause of either cystocele or rectocele. STRAIN- 
 ING AT STOOL forces the pelvic contents downward, and if the 
 the support is weakened there is a tendency to prolapsus of the 
 different organs. To PREVENT THIS during the peurperium always 
 insist on the patient using a BED PAN for at LEAST TWO, better 
 three weeks, after confinement. SUBINVOLUTION of the vagina 
 is a cause, since by it the vaginal walls are weakened and if the 
 bladder becomes distended, cystocele will follow. The OSTEO- 
 PATHIC LESIONS associated with this trouble are located in the 
 SACRAL AND LUMBAR regions since the nerves supplying the 
 vaginal w 7 alls originate there. Any lesion which shuts off 
 a part of the nerve force weakens the muscle which is supplied 
 by that nerve. Since cystocele is the result of the weakening 
 of the anterior vaginal wall we must go to its innervation for the 
 cause; it being found in the muscular or bony lesions which in- 
 hibit the nerve force. 
 
 FREQUENT and IMPERFECT MICTURITION are the principal 
 symptoms of this trouble. The bladder being forced downward 
 produces an abnormal curve of the urethra which prevents the 
 bladder from entirely emptying itself. The retained urine de- 
 composes and sets up a cystitis. There is pain, a burning or
 
 166 
 
 DISEASES OF WOMEN. 
 
 scalding sensation, and vesical tenesmus whenever an attempt is 
 made to evacuate the bladder. The patient describes a lump or 
 protrusion in the anterior vaginal wall which is present when she 
 stands, but disappears when in the recumbent posture. By 
 
 i 
 
 FIG. 57. Cystocele. (From photo of author's case.) 
 
 separating the greater lips this TUMOR can be seen on the anterior 
 vaginal wall. It is covered by rugus vaginal mucous membrane 
 and decreases in size or even completely disappears by evacuating 
 the bladder by means of a catheter.
 
 DISEASES OF THE VULVA. 167 
 
 In mild types the tumor will disappear on digital pressure 
 on the part, especially if the patient is in the genu-pectoral posi- 
 tion when treatment is given. The best position in which to ex- 
 amine a patient with either cystocele or rectocele is the squatting 
 posture, since in this position the prolapsus of the vaginal wall is 
 at its worst. The examination can be readily and best made 
 by means of a hand mirror, so held that the physician standing 
 behind the patient and looking over her shoulder, can see the 
 vulva with the tumor reflected in the glass. There is a dragging 
 sensation or feeling of weight, this being more marked if the 
 bladder is not emptied frequently. Prolapsus of the entire vagina 
 and occasionally of the uterus, accompany this condition, in fact 
 there is some prolapsus of the uterus in every case of cystocele. 
 The ligaments supporting the uterus are weak and relaxed, thus 
 allowing very free, even too free, movement of the uterus. The 
 writer has treated cases that had been diagnosed as cystocele, but 
 on close examination they proved to be cases of prolapsus of the 
 uterus with some eversion of the vaginal walls, but not sufficient 
 to pull the bladder down. The cervix was forced down upon the 
 anterior vaginal wall almost to the external orifice, producing a 
 tumor, a sense of weight and interference with micturition. 
 
 The treatment consists in relieving the pressure on the an- 
 terior vaginal wall and restoring the. tonicity to the supports of 
 the bladder. The PRESSURE can be relieved by frequent evacua- 
 tion of the bladder, if necessary, by the use of the catheter. Some- 
 times the folds in the vaginal wall must be straightened out in 
 order to remedy the curve existing in the urethra. This can best 
 be done, and in some cases only accomplished, by introducing a 
 sound into the urethra and lifting the bladder and anterior va- 
 ginal wall.
 
 168 DISEASES OF WOMEN. 
 
 The SUPPORTS of the bladder can be strengthened by correct- 
 ing the lesions which interfere with their innervation, and strong 
 stimulation over the sacrum, to increase their tonicity. Local 
 digital treatment is indicated in some cases in order to push the 
 bladder up and correct the prolapsed condition of the vagina. 
 This treatment consists principally in a circular motion of the 
 finger; in other words, a rimming out of the vagina. 
 
 ASTRINGENT DOUCHES have been advocated; they will prob- 
 ably relieve temporarily in some cases but will not cure and even 
 make the condition worse if long continued. Sometimes an oper- 
 ation is resorted to by which a portion of the wall is resected; 
 that is, by a transverse denudation, and the edges brought to- 
 gether. When union takes place, the lumen of the vagina is 
 lessened in proportion to the amount of tissue removed. This 
 operation is called colporraphy. 
 
 RECTOCELE. A rectocele is a tumor produced by the rec- 
 tum forcing outward and forward the posterior vaginal wall. 
 Sometimes other structures will force it forward, yet the tumor is 
 still called a rectocele; but technically, a rectocele is a tumor 
 produced by the rectum. 
 
 The causes are similar to those producing cystocele, except 
 that constipation takes the place of a distended bladder. LACER- 
 ATION of the PERINEUM or posterior VAGINAL WALL is a very com- 
 mon cause. This weakens the support of the rectum so that 
 when distended the vaginal wall is forced forward. If the pa- 
 tient is not constipated the rectum is empty only for a short per- 
 iod just preceding defecation, but if constipation is present, the 
 rectum is habitually distended, hence the constant pressure 
 against the weakened posterior vaginal wall, produces a rectocele. 
 As mentioned above, any lesion which affects the tonicity of the 
 vaginal walls will produce either rectocele or cystocele if pressure
 
 DISEASES OF THE VULVA. 169 
 
 is exerted upon them. Lesions, by impairing the nerve force to 
 the pelvic floor, cause the perineal body to sink downward and 
 backward, which thing alone is sufficient to cause rectocele. 
 
 Among the symptoms are found constipation, hemorrhoids, 
 tenesmus, rectal irritation and sometimes inflammation. On 
 
 FIG. 58. Rectocele. (From photo of author's case.) 
 
 vaginal examination the tumor on the posterior wall can be 
 found bulging into the vaginal canal. On rectal examination a 
 fossa or depression will be discovered, corresponding to the cav- 
 ity of the tumor. This is especially noticed in the aged. In 
 such cases, or in chronic or pronounced cases, the cavity some- 
 times measures two or more inches in width. The feces collect 
 there and the rectal wall is depressed, giving rise to chronic con-
 
 170 DISEASES OP WOMEN. 
 
 stipation, which is an effect or result of rectocele rather than a 
 cause. 
 
 The treatment is similar to that of cystocele; that is, endeavor 
 to restore tonicity to the vaginal walls. Relieve the constipa- 
 tion if possible, that being a very important part of the treat- 
 ment. In case the perineal body is torn it should be repaired, 
 'since the w r alls will be weak as long as that injury exists. Local 
 rectal treatments are advisable to remove the folds of the mucous 
 membrane of the rectum. It gets rolled down upon itself and 
 mechanically obstructs the lumen by pulling down the sphincter 
 muscles with it. Local vaginal treatment given to straighten 
 the folds of the vaginal wall and to lift the uterus is to be recom- 
 mended occasionally. In cases in which a laceration of the 
 posterior vaginal wall is the cause, a surgical operation is ad- 
 visable. 
 
 OTHER AFFECTIONS OF THE VAGINA. The vagina is 
 the seat of various other affections, such as innocent and malig- 
 nant growths, papillae, injuries and abnormal discharges. In 
 cases in which there is a twisted pelvis, displaced ilium or sacrum, 
 the blood may become stagnated in the vaginal walls. This 
 venous congestion gives rise to an abnormal discharge which is 
 called vaginal leucorrhea. The walls are smooth and covered 
 with a slimy fluid. Rugae are absent and the canal can be di- 
 lated to a very great extent. The tonicity being lost, the walls 
 tend to prolapse, and with them prolapsus of the uterus, since 
 they form one of the principal supports of the uterus. Along 
 the vaginal walls are found transverse FOLDS OR WRINKLES which 
 have been formed by the relaxed walls rolling upon themselves 
 These not only show that the walls are weakened, but that they 
 are diseased and malnourished. 
 
 Dryness of the vaginal walls indicates that douches, astring-
 
 DISEASES OF THE VULVA. 171 
 
 ent or otherwise, have been used; or that there is a loss, partial 
 or complete, of the SEXUAL DESIRE or activity, or both. 
 
 The use of alum or other astringent douches are advised by 
 some physicians in cases of prolapsus of the vaginal walls, loss of 
 tone, etc. Usually, if the practice is indulged in for a very long 
 time, that is over a month, the mucous secreting glands are de- 
 stroyed or impaired. MOIST vaginal walls, in cases in which the 
 secretion is normal in character, are normal and indicate sexual 
 activity and strength. 
 
 Garrulity of the vagina or vulva or FLATUS VAGINALIS are 
 terms applied to the condition in which air, having entered the 
 vagina, is expelled with a noise. This occurs with movements 
 of the body, especially walking or straining, and is due to a large, 
 relaxed vaginal canal with a patulous OSTIUM VAGINAE resulting 
 from subin volution, caused especially by perineal laceration. 
 In the cases treated by the author, there was a history of douches 
 having been used in all, which thing constituted the most im- 
 portant of all causes. SUBINVOLUTION is also an important 
 cause. In some of these cases there was a cavity around the 
 cervix; that is, the fornices were so distended that a space vary- 
 ing from one to three inches in diameter, was discovered. Pro- 
 lapsus uteri invariably complicates such conditions. The TREAT- 
 MENT consists in restoring tone to the vaginal walls, thereby se- 
 securing coaptation of the walls. This is accomplished by ad- 
 vising the patient to cease using the douche and by correcting 
 lesions which interfere with the normal action of the levator ani 
 muscles. 
 
 Cysts of the vagina are occasionally met with. The writer 
 has seen several cases in which they were as large as hen's eggs. 
 They are quite superficial, thin walled and filled with a clear 
 serous fluid. Surgical interference by which the cyst is removed
 
 172 DISEASES OF WOMEN. 
 
 is the treatment resorted to in most cases. Some, in which the 
 cysts were small, have yielded to osteopathic treatment. 
 
 Atresia of the vagina, either congenital or acquired, is some- 
 times encountered. The writer recently examined a case of con- 
 genital atresia with non-development of the uterus, and under- 
 development of the ovaries. On inspection the hymen was found 
 to be perforate but by widely separating the labia no vaginal 
 opening or canal could be seen. On digital examination the 
 finger could be passed as far as the first joint. On rectal exami- 
 nation no uterus could be outlined. On questioning the pa- 
 tient it was ascertained that she had monthly symptoms of mens- 
 truation which had recurred regularly for several years. The 
 patient was twenty years of age. The conclusion was that it 
 was a case of congenital absence of the vagina and possibly of the 
 uterus ; or since molimina were present, it was a case of developed 
 ovaries with small uterus. In such cases ovariotomy is the only 
 cure. 
 
 Another case examined by Dr. C. E. Still and myself, re- 
 vealed a partly developed vagina and uterus. After inhibition 
 of the clitoris and repeated attempts at vaginal examination the 
 uterus was finally reached. Repeated examinations dilated the 
 vagina to such a degree that menses became normal. The pa- 
 tient, aged nineteen, had never menstruated and had few patho- 
 logical symptoms except the monthly pain. 
 
 Coccydinia is a term used to designate a pain, often intense 
 and constant, located at the coccyx, from which point it radiates 
 to the neighboring parts. Since the disease is almost entirely 
 confined to women it was supposed to be the result of some dis- 
 ease of the female genitalia. However, it most frequently occurs 
 as a result of some injury to or disease of the coccyx. Falls, 
 kicks, difficult parturition, constant sitting and lesions of the
 
 DISEASES OF THE VULVA. 173 
 
 sacrum are common causes. In some cases the lesion is higher, 
 affecting the origin or course of the nerve supplying sensation to 
 the integument over the coccyx, in some the apparent, in others 
 the real seat of the pain. The NERVES INVOLVED are the FIFTH 
 sacral and the COCCYGEAL, both of which end at the tip or pos- 
 terior surface of the coccyx. Since these nerves connect with 
 those supplying the uterus, uterine and ovarian disease may 
 cause a pain to be referred to the coccyx and produce coccydynia. 
 Again, the same segment of the cord which supplies sensation to 
 the coccyx supplies the uterus. 
 
 The PRINCIPAL SYMPTOM is pain on the slightest pressure 
 against the coccyx, even defecation causing pain. In most cases 
 there is a constant ache or pain which is exaggerated on move- 
 ment of the body or especially from sitting long in one position 
 in which the pressure is on the coccyx. 
 
 The treatment should be directed to correcting the displace- 
 ment of the coccyx. This is accomplished partly by external 
 and partly by internal methods. In very tender cases an exter- 
 nal treatment should be used until the parts become less sensi- 
 tive. The internal method consists of introduction of the finger 
 into the rectum, thereby securing such a grasp on the coccyx 
 that reduction is made possible. In other cases, such as a sacral 
 lesion, uterine displacement or those in which the pain is purely 
 reflex, the particular cause must be ascertained and treated ac- 
 cordingly. 
 
 TO CORRECT the various vaginal disturbances, remove ,the 
 lesions found and direct little work to the vagina itself since the 
 effect not the cause, in most diseases is located there. Do not 
 diagnose by symptoms alone. They perhaps help, but examine 
 the anatomy; LOOK FOR SOME ANATOMICAL ABNORMALITY; this 
 is the osteopathic idea. In cases of prolapsus of the vagina, the
 
 174 DISEASES OF WOMEN. 
 
 application of astringents only temporarily increases the tonicity, 
 the walls receiving no nourishment from them. Their use can 
 not build up a part that is weakened by malnutrition. It is 
 treating a symptom, not a cause. Sometimes it is beneficial 
 to introduce the finger and smooth out the folds which exist, but 
 the principal treatment is to correct the lesion found. 
 
 INJURIES TO THE VAGINAL WALLS occur in some cases of 
 labor, however, such injuries can be avoided in a majority of 
 cases by our treatment, that is by producing relaxation of the 
 constrictor muscle fibers of the vagina so as to allow the fetal 
 head to pass. Sometimes foreign bodies are introduced into the 
 vagina, or the walls injured by the patient in the practice of 
 masturbation or in the production of abortion. The writer knew 
 a case of a patient that made a practice of introducing a tallow 
 candle into the vagina in masturbating; followed by a peritonitis 
 that proved almost fatal. 
 
 Awkward or forcible coitus often results in laceration or 
 other injury of the vagina, hymen or vulva. If the vagina is 
 small and the male organ very large, injury of the vaginal walls 
 is almost sure to follow the first coitus. 
 
 The IMPROPER OR UNSKILLFUL use of instruments, or drugs 
 is also to be considered. Too frequent, or rather the use of too 
 much force in giving digital local treatments, may injure the 
 walls. 
 
 Douches. A vaginal douche consists of the injection of a 
 fluid into the vagina or uterus. It consists of water, hot, luke- 
 warm or cold, or it may be medicated. It is a practice that is 
 indulged in by women for the sake of cleanliness or for thera- 
 peutical purposes, and has become such a common one that it 
 is necessary to call attention to some of the evil effects that fol- 
 low its use. Daily douches are recommended by physicians if
 
 DISEASES OF THE VULVA. 175 
 
 there is pelvic inflammation or leucorrhea. The theory is that 
 the inflammation can be reduced and the leucorrheal discharge 
 stopped, apparently forgetting that these are only symptoms 
 of some other disturbance, and that to stop the discharge with- 
 out removing its cause, only makes the condition worse. Douches 
 in which there is alum or witch hazel, are also advised for the 
 above, to be used either one or more times per day. I have 
 asked patients why they use the douche so often, they telling me 
 that their physician advised it in order to cure the prolapsus or 
 leucorrhea, or whatever disease condition existed. Perhaps I 
 will cause some criticism when I make the statement that hot 
 water douches ARE SELDOM, IF EVER INDICATED, AND IN MOST 
 CASES ARE POSITIVELY HARMFUL WHEN USED as physicians or- 
 dinarily direct. 
 
 Let us again consider the secretion of the vaginal walls. It 
 is acid, germicidal and will repel microbic invasion. Examine a 
 normal mucous membrane; it is self-cleansing, self-purifying, 
 and will, so long as it remains normal, take care of itself. Again, 
 what is the effect of water, especially lukewarm water as is gen- 
 erally used, upon the mucous membrane? It washes away the 
 secretion, dilates the vessels, slows the circulation through the 
 membrane and impairs the secretion. It lessens THE VITALITY 
 of the parts, leaving them in a lifeless condition. As an example, 
 examine the fingers of a washerwoman after she has had her hands 
 in water for a little while; the skin of the palm of the hands and 
 fingers will be drawn and puckered. 
 
 If the practice of using douches is indulged in for some time, 
 atony of the vaginal walls must follow with its prolapsus, 
 leucorrhea, weakening of the constrictors and a distended condi- 
 tion of the fornices. I can tell in most cases, by local examina- 
 tion, whether the patient has used douches for any length of time;
 
 176 DISEASES OF WOMEN. 
 
 since it causes a deepening of the FORNICES, leaving a CAVITY 
 sometimes OVER AN INCH IN WIDTH AROUND THE CERVIX. No won- 
 der prolapsus uteri follows this condition. 
 
 In cases of putrid discharges, a douche is sometimes indi- 
 cated, it depending on the individual case. This is given for the 
 sake of cleanliness, not as a curative agent. Douches of a weak 
 solution of sodium chloride have been advised by some osteo- 
 pathic practitioners for leucorrheal conditions. They may be 
 palliative, in that they lessen the amount of the discharge, but 
 they certainly are not curative, in that the effect, not the cause, 
 is treated. 
 
 As a substitute for douches as therapeutical agents I would 
 offer the idea of correcting the anatomical lesion which is causing 
 the weakness or abnormal discharge, instead of applying the 
 water to the symptom. As a rule, a douche of some sort is in- 
 dicated after the menses have completely stopped, in order to 
 remove the odor which clings to the vagina and vulva, but not 
 before, as the flow will be disturbed by it. In cases of malig- 
 nant disease a wash is sometimes used if the odor is very marked.
 
 AFFECTIONS OF THE UTERUS. 177 
 
 AFFECTIONS OF THE UTERUS. 
 
 THE IMPORTANCE. The uterus on account of its LOCA- 
 TION, FUNCTION and the EASE with which it is disturbed, is one 
 of the most frequently diseased organs of the body. It may be 
 affected in various ways; by being displaced, inflamed, or by 
 growths occuring upon it, all of which disturb the sympathetic 
 nervous system which is so intricately and abundantly distri- 
 buted to and around it. The UTERUS, being the organ in which 
 gestation occurs, has a very close connection with the vital or- 
 gans of the mother, since life and nourishment are carried from 
 one to the other. In order to carry nutrition to grow a fetus, 
 the nerve and blood mechanism must be very highly developed. 
 Although this is not so markedly developed before pregnancy, 
 yet the nerve distribution is about the same, a few new nerves 
 are formed during the pregnancy, while the existing nerves are 
 hypertrophied. I mention this in connection with pregnancy 
 because that is the special function of the uterus; to prepare a 
 place for the impregnated ovum, to develop and nourish it while 
 in utero, and then expel the products of conception at the end of 
 the term. Anything which disturbs this function is a cause of 
 uterine disease since it interferes with nature's laws. 
 
 Again, on account of the intimate nervous connection be- 
 tween the uterus and other organs, they may be affected reflexly 
 when the uterus is diseased. All organic life is run by the same force ; 
 this force, apparently to us, is derived from the GREAT SYMPA- 
 THETIC NERVOUS SYSTEM, the branches of which follow all arteries 
 and veins, controling the nourishment and function of each organ. 
 If this system is disturbed in one place the next weakest point 
 
 will suffer secondarily. For instance if the stomach is weakened 
 12
 
 178 DISEASES OF WOMEN. 
 
 by a lesion in the splanchnic area, a displacement of the uterus 
 will affect the stomach, causing various troubles, such as nausea, 
 vomiting, or formation of gas. Various other organs are affect- 
 ed sympathetically, that is, by way of the sympathetic system, 
 the exciting cause being a disturbance of the pelvic organs to 
 which the sympathetic system is most widely distributed, and 
 with which the other viscera are so closely connected. 
 
 Relations of the Uterus. A DISPLACEMENT of the uterus 
 will directly affect the ADJACENT ORGANS, or indirectly as men- 
 tioned above, the distant organs, which are innervated by the 
 same nerve force. The NEIGHBORING ORGANS or adnexa, are the 
 bladder in front and below, the vagina with its fornices below, 
 the rectum behind, the small intestines above, and on either side 
 the broad ligaments, vessels and nerves to the uterus, ovaries 
 and Fallopian tubes. There is no vacant space or cavity in the 
 pelvis. Every crevice and fossa is filled. The uterus, in fact, 
 is surrounded by connective tissue filling in every possible space, 
 which helps to support and protect. Muscle fibers penetrate into 
 the connective tissue giving it strength, contractility and elasticity. 
 The small intestines, being in relation with the upper or back part 
 of the uterus, exert some pressure on it. The uterus becomes 
 pathological when this pressure from enteroptosis is marked. 
 
 An expulsive force acting on the bowels affects the position 
 of both the uterus and bladder. Hence in straining at stool, 
 if the uterine supports are weak, there is a tendency to prolapsus 
 of the uterus, this in turn affects the vaginal walls, Fallopian 
 tubes and ovaries; in short, a disturbance of all the pelvic organs. 
 On account of this INTIMATE RELATION existing between the 
 different pelvic and abdominal organs both as to posi- 
 tion and function, a DISPLACEMENT OF ONE AFFECTS ALL, pro- 
 ducing congestion and probably inflammation.
 
 AFFECTIONS OF THE UTERUS. 
 
 179 
 
 The Normal Position. In order to recognize a displacement of 
 the uterus it is first necessary to acquaint one's self with the normal 
 position. The POSITION of the NORMAL UTERUS is VARIABLE. WHAT 
 
 WOULD BE REGARDED AS NORMAL FOR ONE WOULD BE ABNOR- 
 MAL FOR ANOTHER. There seems to be such a thing as a NORMAL 
 ABNORMALITY; that is the uterus may be apparently or in reality 
 
 
 FIG. 59. The normal po.-iition i>f the uterus. 
 
 very much displaced, yet the patient suffers no inconvenience 
 from it. These things must be considered in making up a cor- 
 rect diagnosis. 
 
 It is common for works on anatomy and gynecology to rep- 
 resent the uterus as having a straight canal, and lying midway
 
 180 
 
 DISEASES OF WOMEN. 
 
 between the symphysis pubis and the hollow of the sacrum, its 
 axis corresponding to that of the inlet of the pelvis, that is, in a 
 position of a very slight ante version. The bladder and rectum 
 are wrongly presupposed to be distended, thus forcing the uterus 
 into the position which is seldom seen in health, or at least it 
 does not remain so for any great length of time. 
 
 The NORMAL POSITION VARIES with the distention of both 
 
 FIG. 60. Movements of the uterus in different degrees of 
 detention of the bladder. 
 
 the bladder and rectum, especially with that of the bladder. 
 Asid? from these movements it has a rhythmical movement, due 
 to respiratory action. The ARC OF MOBILITY, according to Reed, 
 "may vary from 45 degrees to 90 degrees." A uterus may be 
 said to be DISPLACED when it "ceases to manifest these normal 
 variations of position, and when it persistently remains in a posi- 
 tion distinctly at variance with the one which it should occupy
 
 AFFECTIONS OF THE UTERUS. 
 
 181 
 
 under average conditions." Yet on the other hand a UTERUS 
 with TOO GREAT AN ARC of mobility may be said to be DISPLACED. 
 This refers to cases in which the uterus can be moved to any 
 position, or rather one that changes its position to any marked 
 extent, whenever the position of the body is altered. A fixed 
 uterus whatever its position, is abnormal. A CERTAIN AMOUNT 
 OF MOBILITY of the UTERUS is NECESSARY to the functional in- 
 tegrity of all the pelvic viscera. Theoretically, if the patient is 
 in an erect position and the bladder empty, the axis of the uterine 
 
 FIG. 61 X, Plane of pelvic outlet. Y, Plane of pelvic 
 inlet. 1, Symphisis. 2, Sacrum. 3, Rectum. 4, Uterus. 
 5, Vagina. 6, Bladder. 9, Sigmoid flexure of the colon. 
 10, Utero sacral ligaments. (Testut) 
 
 canal lies at about right angles to the vaginal axis. A line drawn 
 from a point midway between the umbilicus and the symphysis 
 pubis to the hollow of the sacrum will fairly represent the long 
 axis of the uterus, the fundus being about on a level with the brim 
 of the true pelvis. The canal of the uterus is slightly curved 
 with its convexity upward and backward. Practically, as 
 stated above, MANY A NORMAL UTERUS, in fact a great majority, 
 
 DO NOT COME UNDER THIS RULE.
 
 182 DISEASES OF WOMEN. 
 
 With the patient in the dorsal position introduce the index 
 finger of the right hand and it will, when carried up, come in 
 contact with the CONICAL SHAPED body projecting into the va- 
 gina, which is the CERVIX. It is firmer than the surrounding 
 tissues, its tonicity varying in different cases, a congestion as in 
 pregnancy producing softening; a deposit of fibrous tissue, pro- 
 ducing hardening. Its DIRECTION will be downward and back- 
 ward; it resting on the ball of the finger when well introduced. 
 If the CERVIX is IN LINE WITH THE VAGINA, or in other words, if 
 the end of the finger comes in contact with the END of the cervix, 
 it indicates a RETROVERSION, or a cervical anteflexion since the 
 
 CERVIX IS THROWN FORWARD IN SUCH DISPLACEMENTS. If the 
 
 end of the cervix is high, and is reached with difficulty, it is prob- 
 ably an ANTEVERSION. In typical cases of flexion the cervix is 
 in about the normal position. 
 
 The POSITION of the BODY is determined by bimanual exami- 
 nation, that is, with the examining finger of the right hand in the 
 vagina and with the other hand making pressure just above the 
 symphysis pubis. (See Fig. 51). By gently raising the uterus 
 with the internal finger the impulse, if the uterus is in normal 
 position, will be transmitted through the long axis of the uterus 
 to the external hand, or an impulse from pressure over the fundus, 
 will be communicated to the internal or examining finger. If 
 slightly anteverted or anteflexed, or if the uterus is carried down- 
 ward and forward by external pressure, the impulse on bimanual 
 examination, will be transmitted through the uterus antero- 
 posteriorly, that is flat wise. Even in the normal uterus, if it 
 is slightly depressed with the external hand, the two surfaces 
 anterior and posterior, instead of the ends of the cervix and fun- 
 dus, are palpated between the two hands. 
 
 "The position of the VIRGIN UTERUS is such that the body is
 
 AFFECTIONS OF THE UTERUS. 183 
 
 joined to the cervix at an obtuse angle, opening downward and 
 forward, so that on an internal examination one can feel a large 
 part of the anterior surface of the uterus through the anterior 
 vaginal cul de sac." If the uterus can not be felt between the 
 two examining hands, that is if the two hands can be so closely 
 approximated that each examining finger or hand can be dis- 
 tinctly felt by the other, it indicates a backward displacement, 
 the particular form of which is determined by the vaginal and 
 rectal examination by which BOTH ENDS OF THE UTERUS are 
 located. In thin subjects, the uterus can be readily outlined by 
 this method, but in the obese it is hard to locate the body and 
 the diagnosis must be made from the vaginal and subjective ex- 
 aminations. 
 
 NORMAL SUPPORTS OF THE UTERUS. SEVERAL FAC- 
 TORS enter into the COMPOSITION of the SUPPORTS of the uterus, 
 it being maintained for the most part by the pelvic floor of which 
 the ligaments are regarded as a part. Normally the ligaments 
 are in a state of relaxation, and limit the normal range of the 
 movements of the uterus; BACKWARD displacement of the BODY 
 is resisted by the round ligaments; BACKWARD displacement of 
 the CERVIX by the utero-vesical ligaments; DOWNWARD and FOR- 
 WARD displacements by the SACRO-UTERINE, and LATERAL dis- 
 placements by the BROAD ligaments. All these ligaments CON- 
 TAIN MUSCLE FIBERS continuous with those of the uterus, hence 
 in a relaxed, enlarged subinvoluted uterus, the ligaments will 
 be in a similar condition, thus allowing the organ too free move- 
 ment or improper support. 
 
 These ligaments, with the exception of the sacro-uterine^ 
 could not support the uterus, since their insertions are on a level 
 with, or at least not below their origin, unless the organ is pro- 
 lapsed. All the ligaments with the vesico-vaginal septum, con-
 
 184 
 
 DISEASES OF WOMEN. 
 
 stitute a suspensory support and SERVE TO ANCHOR the uterus 
 to the surrounding tissues. When there is a uterine displace- 
 ment, traction is brought to bear upon them, which is accompanied 
 by a dull heavy ache or DRAGGING DOWN sensation. Some de- 
 
 FIG. 62. Uterus w ith pressure equal in all directions. Pelvic floor 
 
 Intact. 
 
 scribe it as a constant pulling or stretching of the structures of 
 the pelvis. 
 
 When no extra pressure is brought to bear on the uterus, 
 it is almost ENTIRELY SUPPORTED, according to Byford, by con-
 
 AFFECTIONS OF THE UTERUS. 
 
 185 
 
 nective tissue. This tissue has in it muscle fibers, hence it is 
 especially CONTRACTILE and ELASTIC. 
 
 In the treatment of displacements, one of the objects to be 
 attained is restoration to these ligaments and connective tissue, 
 
 FIG. 63. Uterus -with pelvic pressure exerted downward from lacerated 
 pelvic floor. 
 
 of normal tone and contractility. This is accomplished prin- 
 cipally by external treatment correcting, and removing the causes 
 that weaken it.
 
 186 DISEASES OF WOMEN. 
 
 The pelvic floor, with its muscles and ligaments, form the 
 REAL SUPPORT of the uterus, not so much by actual contact, the 
 uterus resting on it, but by SECURELY CLOSING THE OUTLET OF 
 THE TRUE PELVIS, thus forming a closed cavity. In this cavity 
 the pressure is equal in all directions as illustrated in Fig. 62. 
 This has been represented by a pail of water; while the bottom of 
 the pail is intact, pressure is as great upon the sides of the pail as 
 on the bottom, but if the bottom were punctured, nearly all the 
 pressure would be downward. "The contents of the pelvis are 
 semifluid and of nearly equal consistence." From this it would 
 seem that the pressure would be about equal in all directions. 
 If the vaginal walls are held closely together the intrapelvic 
 pressure is undisturbed, but if the floor is weakened or the peri- 
 neal body lacerated, air will probably enter the pelvic cavity 
 thus causing the pressure to be exerted downward. 
 
 This is better illustrated by considering that the abdomen 
 exerts a suction FORCE on the pelvic viscera which force is called 
 the retentive power of the abdomen. This is illustrated by the 
 physical fact that "in tapping a barrel which is filled with a liquid 
 more than one opening has to be made before the contents readily 
 flow." This is due to air pressure, the sides of the vessel being 
 unyielding to the external air pressure. Thus it is reasoned that 
 the RETENTIVE POWER OF THE ABDOMEN is in proportion to the 
 strength of the abdominal walls. The weaker and more re- 
 laxed the abdominal walls, the greater likelihood of a DISPLACE- 
 MENT, or in other words the ABDOMINAL WALLS FORM, in this 
 
 Way, AN IMPORTANT SUPPORT OF THE UTERUS. 
 
 The vaginal walls, being a part of the floor, also help to sup- 
 port the uterus. A weakness of the walls is an indication and is 
 a forerunner of prolapsus uteri. In cystocele and rectocele, which 
 conditions are dependent on a relaxed vaginal wall, uterine dis-
 
 AFFECTIONS OF THE UTERUS. 187 
 
 placements are almost invariably found. Schultze says, "The 
 muscular and connective tissues of the vagina are directly con- 
 tinuous with the same tissues of the uterus, and the rigidity of 
 the vagina and its immediate surroundings, as well as of the mus- 
 cular tissues and fascia of the pelvic floor, is an essential factor 
 in securing the position of the uterus." 
 
 The NORMAL POSITION of the organ acts as a preventative 
 to displacements in that it is at right angles to the vagina. The 
 pressure of the abdominal viscera forces it farther into anteversion. 
 On account of this fact the position, at least, tends to prevent 
 "FALLING OF THE WOMB" or prolapsus. 
 
 In considering the supports of the uterus ALL OF THEM MUST 
 be CONSIDERED together since THEY ACT TOGETHER. Not the 
 pelvic floor alone, nor the ligaments of themselves support the 
 uterus ; but the pelvic floor, the ligaments, the mtra-pelvic pressure, 
 the action of the intestines, the contraction of the diaphragm 
 and the intra-abdominal pressure, all unite to keep the uterus 
 in its proper place. 
 
 Varieties of Displacements. The uterus may be displaced back- 
 ward, forward, downward to one side or upward, the last named 
 displacement is properly called an ASCENT, or mal-location of 
 the uterus. The writer has seen a few cases of this form, it being 
 a comparatively rare kind of displacement. 
 
 The BACKWARD displacements are RETROVERSION and RE- 
 TROFLEXION. Forward displacements are called ANTEVERSION 
 and ANTEFLEXION The downward displacement is called PRO- 
 LAPSUS, or if the displacement is complete it is called PROCIDENTIA. 
 The lateral displacements are called latero-version or latero- 
 flexion ; when to the right dextro-, if to the left, sinistro-lateral 
 flexion or version . Often there is a combination of some of these 
 displacements, the most common of which is an anteflexion com-
 
 188 DISEASES OF WOMEN. 
 
 plicated by a retro version. The anteflexion is usually primary. 
 The walls undergo changes which make straightening of them 
 impossible. If, while in this condition, the patient has a fall or 
 anything which suddenly changes the intra-abdominal pressure, 
 it will cause the uterus to retro vert, although it retains its bent 
 form. On examination the concavity can be felt through the 
 anterior fornix, although the body is back. 
 
 GENERAL SYMPTOMS OF A DISPLACEMENT. The most 
 common symptoms which belong to all displacements are BACK- 
 ACHE, a SENSE of HEAVINESS in the pelvis and lower limbs, inter- 
 ference with walking or standing, PAIN referred to the pelvic 
 organs and limbs, such as cramping, sciatica and coldness, and 
 MENSTRUAL DISTURBANCES, either dysmenorrhea or menorrhagia. 
 Any displacement affects the pelvic circulation since the uterus 
 is so very vascular and the blood pressure low. The ovaries 
 are very commonly affected by any form of displacement. The 
 characteristic pain or cramp in the region of the ovary is the 
 most important of the symptoms resulting from ovarian dis- 
 turbances. Tenderness is found on palpation of the lower part 
 of the abdomen, particularly in the ILIAC FOSSAE, the sacro-iliac 
 synchondrosis and at or near the spine of fifth lumbar vertebra. 
 
 The reflex symptoms are HEADACHE, suboccipital and ver- 
 tical, ACHING BETWEEN THE SHOULDERS, nervousness, SPINAL 
 
 IRRITATION or tenderness, STOMACH troubles, neuralgias and 
 forms of paralysis, hysteria and neurasthenia. These symp- 
 toms belong to nearly all displacements, while special symptoms 
 indicate the particular kind of displacement. 
 
 PROLAPSUS OF THE UTERUS. Prolapsus uteri is a con- 
 dition in which the uterus SINKS TO A LOWER LEVEL in the pelvis 
 than is found in a normal subject, which is accompanied by a re- 
 laxation of the pelvic floor, prolapsus of the bladder and vagina.
 
 AFFECTIONS OF THE UTERUS. 189 
 
 There are several forms which are classified according to their 
 degrees. The MILDEST type, characterized by some retrover- 
 vesion and descent, constitutes the first degree. If the CERVIX 
 
 APPROACHES THE VAGINAL OUTLET it IS Called the SECOND DEGREE, 
 
 and if the uterus is OUTSIDE THE VAGINAL ORIFICE it is called the 
 
 FIG. 64. Prolapsus uteri. 
 
 IHIRD DEGREE, or procidentia. These forms or degrees of pro- 
 lapsus run into each other, it being impossible to differentiate 
 between them unless they are typical forms.
 
 190 DISEASES OF WOMEN. 
 
 Prolapsus is the most common of all uterine displacements, 
 as well as the first displacement mentioned in literature. Among 
 the laity it is called " FALLING OF THE WOMB," or "FEMALE 
 WEAKNESS" and its importance is understood by most patients 
 suffering with it. Most of them, as well as physicians, so 
 appreciate its significance that almost every conceivable remedy 
 has been applied, ranging from medicinal applications to artifi- 
 cial supports. 
 
 Some of the cases of prolapsus are obscure, if examined in 
 the usual way, but if examined in the ERECT POSTURE the pro- 
 lapsus, as well as the degree can then be definitely ascertained. 
 Prolapsus is nearly always accompanied by retro-displacement, 
 it being almost impossible for the uterus to prolapse without a 
 retroversion, since its axes is at right angles to the vaginal axis 
 and must turn so that the axes will correspond. Retroversion, 
 to such a degree that the axes of the uterus and vagina coincide, 
 is called the first degree of prolapsus. Thus the PATHOLOGICAL 
 EVENTS of prolapsus uteri taken in their sequence are (1) weak- 
 ening of uterine supports, (2) retroversion of the uterus, (3) 
 descent of uterus, (4) commencing prolapsus of vagina, (5) 
 commencing inversion of the vagina, (6) prolapsus of bladder 
 and (7), the above named conditions gradually increasing in 
 intensity, especially the sinking of the uterus lower and lower 
 until, unless checked, procidentia takes place. There is CON- 
 GESTIVE HYPERTROPHY of the uterus, especially of the cervix. 
 In some this is so marked that the term hypertrophic elongation 
 or pseudo-prolapsus has been applied. 
 
 CAUSES. Prolapsus uteri is DUE TO ONE OF THREE 
 things; either a weakness of the supports or increase in size of 
 the parts to be supported, or sudden increase of intra-abdominal 
 pressure. Thus it may come on suddenly, as a result of a severe
 
 AFFECTIONS OF THE UTERUS. 191 
 
 strain or fall, which suddenly increases the intrapelvic pressure. 
 WEAKENING of the pelvic floor implies that the nerve sup- 
 ply is interfered with, a condition of malnutrition existing. 
 The NERVE supply is principally from the anterior SACRAL nerves, 
 with the PUDIC also sending some branches to it. The pudic 
 nerve being the nerve of sensation in coition, loss of sexual vigor 
 from excessive venery or from a lesion affecting it, will help weak- 
 en the floor, since the PUDIC NERVE is DISTRIBUTED TO THE FLOOR. 
 Tracing the sacral nerves to their origin and noticing their rela- 
 tions and where they make their exit, it can be readily seen that 
 
 a DISPLACEMENT of the LUMBAR VERTEBRAE, SACRUM, INNOMI- 
 NATE bones, or coccyx, will affect them either by direct pressure 
 or indirectly by muscular contraction. The lumbar region in 
 many is posterior with muscular lesions; in some the spine is 
 rigid, in others unduly relaxed. This relaxation extends to the 
 pelvic structures and abdominal wall. In other cases in which 
 the spine is rigid, the INTERVERTEBRAL DISCS ARE THINNED from 
 pressure and the vertebrae approximated, the latter of which re- 
 sults in a LESSENING IN size of the INTERVERTEBRAL FORAMINA. 
 This condition is soon followed by an impairment of the nerves 
 and vessels in relation, which soon results in paresis or weaken- 
 ing of the pelvic and abdominal viscera. 
 
 A weakening of these nerves causes a weakening of the mus- 
 cles supplied by them, since the strength of the muscle depends 
 upon the amount of the nerve force going to it. Take for in- 
 stance, an insane man during a paroxysm; it requiring several 
 men to control him, otherwise one man can easily hold him dur- 
 ing the quiescent stage. The man has the same muscles during 
 each stage, but the explosion of nerve force in the one. increases 
 to a marvelous extent the muscular power. Applying this to 
 the pelvic floor the muscles may still retain their volume, but if
 
 192 DISEASES OF WOMEN. 
 
 their food or nerve force is shut off, they weaken, letting to a 
 lower level the parts which should be supported by them. This 
 is the IMPORTANT CAUSE of prolapsus and one not mentioned in 
 medical literature. 
 
 The floor is frequently injured and weakened by LACERA- 
 TION during delivery, this laceration usually taking place in the 
 KEY STONE of the pelvic floor, or perineal body. This is a condi- 
 tion that should not be permitted to happen in cases in which no 
 deformitiy exists, and I consider it carelessness or ignorance if it 
 is permitted to occur. After the perineal body is torn it hinders 
 or prevents approximation of the vaginal walls, permitting air 
 to enter the pelvic cavity, which normally is air tight. Even in 
 coition, or digital examination, no air enters on account of the 
 vaginal walls closing so completely around the part introduced. 
 If this injury exists the walls are separated and the equilibrium 
 of the pelvic contents destroyed, the pressure being exerted 
 downward instead of being exerted equally in all directions. 
 Laceration of the perineum weakens the pelvic floor, since it sets 
 up a congestion or inflammation which disturbs nutrition. The 
 floor is engorged with venous blood, its specific gravity increased 
 and it sinks to a lower level. Prolapsus of the vaginal walls, 
 pulls the cervix down by exerting traction on it. This brings the 
 uterus into a position of retro version, which position is followed 
 almost invariably by descent or prolapsus uteri. 
 
 WEAKENING, with relaxation and stretching of the utero- 
 sacral ligaments, is one of the most important of single causes of 
 prolapsus. The function of these ligaments is to hold the lower 
 part of the uterus in position, that is up and back. It does this 
 by SUSPENSION; the ligaments being almost vertical, when pa- 
 tient is in the erect posture. When the ligaments relax, the cervix 
 drops forward, and downward, thro wing the uterus into retro version.
 
 AFFECTIONS OF THE UTERUS. 193 
 
 This change in the position of the uterus is primary to, and takes 
 place in nearly all cases of retroversion and prolapsus. These 
 ligaments HAVE MUSCLE FIBERS which are supplied by the anterior 
 division of the sacral nerves in relation. Hence lesions, by affect- 
 ing these nerves, are important causes of prolapsus since their 
 relaxation is due to an impairment of nerve force or nutrition, 
 this being the usual effect of lesions on motor nerves. Kelly 
 has described RELAXATION as the MOST IMPORTANT of all in- 
 juries of the perineum and pelvic floor. 
 
 Increase in weight of the uterus is a cause of prolapsus. In 
 cases of subinvolution in which the condition has existed for 
 sometime, the continual downward pressure will, in time, stretch 
 and weaken the supports, and prolapsus will result. If the pa- 
 tient, after delivery, gets up before involution is well under way, 
 the uterus, being already in a retroverted condition, will be forced 
 downward, sometimes resulting in a serious prolapsus. In these 
 cases there is also a weakening of the vaginal walls from subin- 
 volution. If in case of parturition the uterus is left in the hollow 
 of the sacrum, the thickened ligaments will become permanently 
 stretched, thus losing their contractile power, leaving the uterus 
 in this retroverted and prolapsed condition. 
 
 In FIBROID TUMORS of the uterus it may be forced down by 
 sheer weight, although the tumor sometimes develops upward 
 and draws the uterus with it. The writer recalls a case of a lady 
 sixty-five years of age who suffered with procidentia caused by 
 a subperitoneal fibroid tumor. The tumor caused few of the 
 ordinary discomforts which usually attend fibroids; the uterine 
 displacement with a few pressure pains being the most noticeable. 
 
 PRESSURE, exerted on the pelvic contents by the wearing of 
 heavy skirts or tight clothing, produces congestion of the uterus, 
 increases its specific gravity, and as a result, it is forced farther 
 
 13
 
 194 DISEASES OF WOMEN. 
 
 down in the pelvis. In enteroptosis the condition is similar, that 
 is, increased pelvic pressure and interference with the venous 
 return. 
 
 Sudden falls or strains derange the intra-pelvic and intra- 
 abdominal pressure and if the bladder is full at that time, it may 
 result in retroversion and prolapsus. One of the worst cases of 
 prolapsus that the writer ever treated was the result of a back- 
 ward fall, bringing on an ACUTE retroversion and prolapsus. 
 STRAINING AT STOOL also increases the intra-pelvic pressure, and 
 tends to force the uterus downward. This is especially true if 
 done within a few weeks after labor, that is during thepuerperium, 
 and constitutes a common exciting cause of prolapsus. The 
 uterus at that time is large and heavy and the pelvic floor weak- 
 ened, which conditions are aggravated by constipation which 
 usually complicates. With such conditions, straining at stool 
 when patient is in the squatting posture will almost invariably 
 bring on descent of the uterus. To avoid this in a great meas- 
 ure, advise the patient to use a bed pan for several weeks after 
 labor. 
 
 A too ROOMY pelvis tends to permit of displacement, descent 
 being the most common. Neglect of the evacuation of the bowels 
 and the bladder increases the tendency to prolapsus whenever 
 the patient strains or carries a heavy weight. Stooping over a 
 cradle and repeatedly lifting a large fat baby is ALMOST SURE to 
 PRODUCE DISPLACEMENT of the uterus, if oft repeated, within a 
 year or so after confinement. The condition of the uterine liga- 
 ments and supports determines the frequency of it. The awkward 
 position, the strain and the condition of weakness and relaxa- 
 tion of all the pelvic contents, make it possible. Also the stooping 
 posture lessens the inclination or obliquity of the pelvis, thus 
 allowing the abdominal contents to press more directly on the
 
 AFFECTIONS OF THE UTERUS. 195 
 
 uterus. Severe paroxysms of coughing or violent action of the 
 abdominal or other muscles, such as in epileptic convulsions, 
 force the uterus down, since such things increase the intra-abdomi- 
 nal pressure. 
 
 In certain occupations in which the patient is on her feet a 
 great deal and when there is malnutrition and poor air, there is 
 a tendency to prolapsus of the uterus. This is proven by the 
 number of school teachers and shop girls, who have this form of 
 uterine displacement. 
 
 Pressure directed on the uterus from above is a prolific cause 
 of prolapsus. This pressure is the result of many causes, belts, 
 tight clothing, and heavy skirts supported by bands are the most 
 important. Waitresses in hotels usually have prolapsus or a 
 backward displacement on account of the way they carry the 
 platters, this tilting the pelvis, thus throwing the strain on 
 the abdominal muscles, which increases the tendency to pro- 
 lapsus. If the uterus is small and the outlet is large, such as is 
 found in atrophy of the vaginal walls, it may be forced down- 
 ward. This is a condition found in the aged and is supposed to 
 be due to senile atrophy of the vagina. The writer recently saw 
 a case of complete procidentia which had come on suddenly at 
 the menopause; it caused comparatively little pain, she replacing 
 the organ some ten to twenty times each day. The cervix was 
 so excoriated that it appeared to be of a cancerous nature. This 
 form of prolapsus yields very slowly to treatment on account of 
 the age and the relaxed condition of the supports. 
 
 SYMPTOMS. The severity of the symptoms does not de- 
 pend upon the degree of the displacement, but on the nervous 
 condition of the patient, mode of onset, amount of inflammation, 
 length of standing and organs involved. I have seen cases of 
 
 COMPLETE PROCIDENTIA, which CAUSED VERY LITTLE PAIN, while
 
 196 DISEASES OF WOMEN. 
 
 on the other hand cases of PROLAPSUS of the FIRST DEGREE 
 caused the patient GREAT SUFFERING, and almost unbearable 
 pain and nervousness. 
 
 If the prolapsus comes on gradually there are no character- 
 istic symptoms in the early stages. If brought on suddenly 
 the symptoms are acute and demand immediate attention. In 
 ordinary cases the patient complains of sensation of weight or 
 heaviness in the pelvis; this is increased by the patient standing 
 on her feet or walking any distance, and is worse toward evening, 
 that is after standing for several hours. There also exists rec- 
 tal and vesical irritation produced by the traction exerted on the 
 vesico- and sacro-uterine ligaments. 
 
 PAIN is referred to the interscapular region, which increases 
 when the patient uses the arms. This pain is described as an 
 ache which is nearly constant, and is dull in character. The 
 possible explanation of it is that the mammae, which constitute 
 a part of the generative system, are supplied with nerves which 
 have their spinal center in this region; and a disturbance of one 
 part, viz., the uterus, would reflexly affect the other, which in 
 this case is manifest by an ache in the region supplied by nerves 
 which come from the same segment of the cord that supplies the 
 mammary glands. The pain is sometimes transmitted to the 
 limbs, either producing an aching or cramping of the muscles. 
 CRAMPING of the calf of the leg is possibly due to the disturb- 
 ance of the pudendal branch of the small sciatic, the impulses being 
 reflected over the small sciatic to the calf of the leg where the 
 nerve terminates. 
 
 Menstrual disturbances result from prolapsus; MENORRHA- 
 GIA being the most common. The uterus is badly congested and 
 the blood circulates very slowly. This surplus of venous blood 
 finds escape at the menstrual time in the form of a menorrhagia.
 
 AFFECTIONS OF THE UTERUS. 197 
 
 Not only is the uterus congested but the circulation of the vaginal 
 walls is affected. This interferes with secretion and produces 
 a hy perse ere tion or leucorrhea. LEUCORRHEA DEPENDS UPON 
 CONGESTION, and since congestion results from prolapsus it is 
 easy to see how naturally leucorrhea, both uterine and vaginal, 
 would accompany this form of displacement. DYSMENORRHEA 
 occurs in some cases, it being due to (1) CLOTTED blood, the 
 uterus having to go into labor to expel the clots, or (2) IMPAIR- 
 MENT OF THE EXPELLANT forces of the uterus, or (3) pathological 
 congestion of the uterine substance by which the blood pressure 
 is raised to the painful point, any or all of which occur in typical 
 cases of prolapsus. 
 
 Prolapsus of the uterus produces a GENERAL WEAKNESS of 
 the body. This is a result of disturbances of nutrition and loss 
 of nerve force, and partly the result of worrying over the condi- 
 tion, as falling of the womb is a condition which is dreaded by 
 all women. 
 
 The patient is unable to exercise without getting greatly 
 fatigued. There is palpitation of the heart, shortness of the 
 breath and inability to lift anything heavy. Rectocele and 
 cystocele often accompany prolapsus, especially if the vaginal 
 walls are very much affected, and they are always affected in 
 cases in which the prolapsus is very marked or of very long stand- 
 ing. These conditions affect the rectum and bladder, often 
 causing painful and severe functional disturbances, such as tenes- 
 mus, rectal pain or irritation, coccydynia, and disturbances of 
 defecation. 
 
 In procidentia the exposed part may become chafed and 
 irritated from friction of the clothing in walking, causing extreme 
 suffering and giving it a malignant appearance. 
 
 PHYSICAL SIGNS. The above symptoms are only indica-
 
 198 DISEASES OF WOMEN. 
 
 tions of prolapsus, prompting us to make a local examination to 
 clear up the diagnosis. Should there be the first degree of pro- 
 lapsus, the finger passed up through the vagina, will meet with 
 the cervix low down and in a line corresppnding with the vaginal 
 axis. The body will be found backward, indicating a position 
 of retroversion. This is ascertained by PALPATING the BODY OR 
 FUNDUS through the POSTERIOR FORNIX or rectum and BY NOT 
 FINDING the uterus on PALPATION through the ANTERIOR FORNIX. 
 Also on this account, that is the uterus being back, the hands can 
 be approximated immediately behind the pubes and anterior 
 to the uterus; that is each hand, one being internal and the other 
 external, can be palpated by the other. The vaginal walls are 
 usually very smooth and covered with transverse folds, not rugae. 
 
 If the second degree of prolapsus exists, the cervix will be 
 found at the vaginal orifice, which is best ascertained in the sitting 
 or erect posture. The body is turned backward and the upper 
 portion of the vaginal walls rolled downward ; the uterus is grasped 
 by the sphincter muscles and in conjunction with the uterine 
 ligaments a complete prolapsus is prevented, unless there is ex- 
 cessive weakness. Complete prolapsus is diagnosed by inspec- 
 tion and palpation. The os can be seen and the different parts 
 of the uterus can be palpated, making the diagnosis certain. 
 
 DIAGNOSIS. Any of the varieties of prolapsus may some- 
 times be confounded with polypi, inversion of the uterus or hyper- 
 trophy and elongation of the cervix, which produces a 
 pseudo-prolapsus. In a POLYPUS, the shape and con- 
 sistency of the presenting body is different and there is the ab- 
 sence of the cervix and os. INVERSION is diagnosed by the ab- 
 sence of the os and cervix, the larger end or fundus, presenting. 
 The COVERING of the presenting part will be different; in prolap- 
 sus it is glistening; in inversion it is raw, bleeding and irritable.
 
 AFFECTIONS OF THE UTERUS. 199 
 
 Inversion occurs at or immediately after childbirth, the history 
 helping to make a diagnosis. In HYPERTROPHY of the cervix , 
 bimanual examination, and the use of the sound, will clear up 
 the diagnosis. If the uterine canal is found very much elongated 
 it is probably a condition of hypertrophy of the cervix. The 
 diagnosis of prolapsus really depends on locating the cervix at a 
 lower level than normal and finding the fundus backward and 
 downward, this being done by digital and bimanual examination. 
 THE EFFECT ON THE ADJACENT ORGANS. The ORGANS 
 ADJACENT to the uterus are the bladder, rectum, Fallopian tubes 
 and the ovaries. The bladder is pulled down by the vesico- 
 uterine ligaments until quite a noticeable cystocele is formed. 
 The tension resulting from the continued traction irritates it, 
 and is the cause of frequent micturition. The URETHRA is bent 
 on itself and on this account COMPLETE evacuation of the bladder 
 does not occur at micturition. This is accompanied or followed 
 by decomposition of the residual urine which gives rise to cystitis, 
 pyelitis, or uremic symptoms. Traction is exerted on the rectum 
 by the retco-and sacro-uterine ligaments?, producing an irritation 
 which often results in tenesmus. The Fallopian tubes are drawn 
 downward, pulling the ovaries with them. This produces con- 
 gestion of the ovaries and tubes, causing pain and menstrual 
 disorders. Immediately behind the uterus are the roots of the 
 sciatic nerve, the sympathetic plexuses and ganglia and the an- 
 terior divisions of the sacral nerves. The obturator nerve is 
 also near, as well as the secondary plexuses derived from the 
 hypogastric plexus. The ligaments are put on a stretch; and in 
 the case of the broad ligaments, between the layers of which 
 passes all the blood to and from the uterus, a considerable vascu- 
 lar disturbance is produced, usually in the form of a venous con- 
 gestion. The force exerted by the prolapsed uterus pulling on
 
 200 DISEASES OF WOMEN. 
 
 the different ligaments produces a PAIN which is referred to the 
 BACK, or pressure is exerted directly on the nerves causing neu- 
 ralgia, or other disturbances of the limbs. The VAGINAL WALLS 
 are reduplicated, especially so in the worst forms of prolapsus. 
 The pouch of Douglas is elongated and pulled down and with it, 
 in most cases of marked prolapsus, a part of the small intestines 
 and peritoneum, giving rise to a condition called ENTEROCELE. 
 In short, every adjacent organ or structure is more or less affect- 
 ed by prolapsus on account of pressure directly on, or interfer- 
 ence with circulation and nerve supply, to such adjacent tissues. 
 
 The complications of prolapsus are congestion or inflamma- 
 tion of the uterus and its appendages, such as metritis, salpingi- 
 tis, ovaritis and peritonitis. CONGESTIVE HYPERTROPHY occurs 
 in most chronic cases. Cystocele and rectocele are common; 
 sterility, leucorrhea and disorders of bladder and rectum are 
 found in many cases. SCIATICA is one of the common and dis- 
 agreeable complications. The lower limbs and FEET ARE COLD 
 and sometimes the ankles are edematous and the veins varicose. 
 The patient complains of a heavy, achy, tired feeling to such an 
 extent that she can with difficulty draw one limb after another. 
 
 THE PROGNOSIS depends upon the condition of the uterus 
 and vaginal walls, the character of the complication and whether 
 or not she can take care of herself during the treatment. In long 
 standing cases in which the entire system is poorly nourished, a 
 cure will be slow ; in recent cases in which the tonicity of the floor 
 or part of it is retained, the prognosis is better. In cases in which 
 the displacement is the RESULT OF CAUSES WHICH HAVE BEEN IN 
 OPERATION FOR A LONG TIME, the outlook is POOR. In cases in 
 which the trouble came on suddenly, such as the result of a fall, 
 the prognosis is GOOD. In the first class of cases the supports 
 have to be strengthened by correcting the bony lesions, LOCAL
 
 AFFECTIONS OF THE UTERUS. 201 
 
 TREATMENT BEING SECONDARY. In the second class of cases a 
 cure is usually effected by SIMPLY REPLACING THE ORGAN. If 
 the vagina is large and the pelvic floor relaxed, the case is a hard 
 one to cure, and especially so if the patient has to be on the feet 
 a great deal. I regard it as one of the hardest of uterine dis- 
 placements to cure; first, on account of the NATURE of the CAUSES, 
 and second, on account of its POSITION, which allows it to drop 
 lower when the patient strains, or from pressure in ordinary res- 
 piration, it being acted upon directly by force of gravity. If 
 the cause is apparent the prognosis is more favorable, but in a 
 GREAT MANY CASES the primary cause is obscure, making the prog- 
 nosis uncertain. 
 
 SUDDEN PROLAPSUS may come on from any VIOLENT effort 
 in which the abdominal muscles are forcibly contracted, or if 
 the intra-abdominal pressure is suddenly increased from any 
 cause whatever. If the uterus is diseased or the supports weak- 
 ened, a sudden displacement will usually take place if the patient 
 has a fall or lifts any heavy weight. In an instant the patient 
 feels that something has given away within her, becomes pros- 
 trated and suffers pain of an EXPULSIVE character. Sometimes 
 the stomach will be affected reflexly, causing nausea and vomit- 
 ing. If the displacement is not corrected at once, the irrita- 
 tion will spread to the adjacent parts and inflammation, such as 
 peritonitis, will set in with its attending evils. 
 
 TREATMENT. In taking up the treatment of prolapsus, 
 the prophylactic treatment will be considered first. The pro- 
 phylactic treatment of prolapsus of the uterus is one directed to 
 prevent its occurence. In order to prevent prolapsus, the pelvic 
 floor and other supports must be KEPT INTACT and the UTERUS 
 
 PREVENTED FROM BECOMING TOO HEAVY. 
 
 The FIRST is accomplished by PREVENTING LACERATION and
 
 202 DISEASES OF WOMEN. 
 
 injuries during childbirth. CORRECT ANY BONY DISPLACEMENT 
 as soon as it occurs, this preventing an impairment of the nutri- 
 tion of the pelvic floor. Avoid use of WARM WATER douches, or 
 in fact avoid frequent douching of any description. Take plenty 
 of exercise with deep breathing; respiration affecting to a marked 
 extent the pelvic circulation. Avoid lifting heavy weights or 
 straining the abdominal muscles, especially if the patient is not 
 very strong. The carrying around of a large overgrown baby has 
 broken down the health of many a mother. Avoid wearing heavy 
 skirts supported by bands encircling the waist. AVOID tight 
 clothes, they interfere with deep respiration, mechanically ob- 
 struct the blood flow, and cause weakening of muscles of both 
 the back and abdomen. Have the patient attend to the calls 
 of nature; this will prevent displacements which would other- 
 wise tend to occur. The straining at stool in a constipated con- 
 dition of the bowels, forces the uterus to a lower level, and if the 
 constipation exists for any length of time the uterus will pro- 
 lapse. Care should be taken that the patient does not walk too 
 much, or stand on her feet too soon after delivery, this inter- 
 fering with involution of the uterus and its appendages. 
 
 The object to be attained in the treatment of a prolapsus 
 after it has occurred is, first to REPLACE it, and second to KEEP 
 IT IN POSITION. Sometimes palliative treatments are indicated 
 when it is impossible to replace or keep the uterus in place after 
 it is once corrected. 
 
 REPLACEMENT. Generally, little difficulty is experienced 
 in replacing a prolapsed uterus unless there are obstructions 
 such as adhesions, tumors or inflammatory conditions which 
 hinder. 
 
 The contra-indications to, or conditions which make re- 
 placement impossible or difficult, are, inflammatory conditions
 
 AFFECTIONS OF THE UTERUS. 203 
 
 of the vagina, uterus or its appendages, pelvic peritonitis and 
 cellulitis, adhesions and pelvic growths. If adhesions exist, 
 and this can be ascertained if there is limitation of motion in a 
 certain direction or by feeling the adhesive bands, care should be 
 used, since a hemorrhage followed by inflammation will result, 
 if they are forcibly broken up. 
 
 In replacing any of the various forms of uterine displace- 
 ment, have the patient ASSUME A POSITION so that the FORCE OF 
 GRAVITY will help in the reduction. In backward displacements 
 the best position for their correction is the semi-knee chest which 
 is obtained by placing the patient on the left side, then raising 
 the hips to an angle of 45 degrees or more. The hips can be held 
 by the operator's knee or by other support, such as a pillow. This 
 position permits of local vaginal work, the use of two hands and 
 force of gravity. In cases OF PROLAPSUS, since there is also re- 
 troversion, it is advisable to place the patient in the semi-knee- 
 chest position; the uterus then having a tendency to spontaneous 
 reduction, since this causes the pelvic and abdominal viscera to 
 gravitate toward the diaphragm, this relieving the pressure on 
 the uterus. A hard unyielding table is best; the knees sinking 
 in, hindering the operation if a soft yielding bed is used; the ob- 
 ject being to elevate the hips, and depress the chest as much as 
 possible. 
 
 Use gentle manipulation over the abdomen for some five or 
 ten minutes if the pelvis is much congested or inflamed, before 
 attempting to reduce the displacement, by which the viscera are 
 pulled out of the true pelvis and the space anterior to the uterus. 
 This allows the blood, on account of the changed position, to 
 DRAIN OUT of the uterus; it always being full of blood when in a 
 prolapsed condition. While in this position, the index finger or 
 both index and middle fingers, are introduced as far as the va-
 
 204 DISEASES OF WOMEN. 
 
 ginal junction. By separating the two vaginal walls, air enters 
 the vaginal canal and by means of a slight pressure on the pos- 
 terior part of the uterus, and backward traction on the cervix, it 
 will assume its normal position, unless held by adhesions or caught 
 behind the promontory of the sacrum. No violent or sudden 
 force should be exerted, but a steady pressure by which it is 
 GRADUALLY pushed into place. When two fingers are used make 
 pressure with the middle finger in the posterior fornix upward 
 and forward, and with the index finger exert backward traction 
 on the cervix. In this way the uterus if it has retained its tone, 
 is pried into normal position. If the uterus is soft and flexible 
 so that it bends instead of turns, pressure with the internal finger 
 should be made high up in the posterior fornix. With the ex- 
 ternal hand make deep pressure over the abdomen, finally getting 
 the hand back of the uterus and the fingers of the two hands 
 approximated. This is accomplished best by beginning the EX- 
 TERNAL PRESSURE HIGH, that is on a LEVEL with the SACRAL 
 PROMONTORY. After the fingers are approximated, lift the uterus 
 upward and forward, thus carrying it into normal position. This 
 can only be done in subjects that are comparatively free from 
 pelvic inflammation and are not too obese. 
 
 In the above methods it is not advisable to balloon the va- 
 gina before replacement; since by so doing the uterus may be 
 forced to the hollow of the sacrum, that is in extreme retrover- 
 sion with anteflexion; it accommodating itself to the shape of 
 the anterior surface of the sacrum, from which position it is hard 
 to remove. MANY AN ERROR has been made in not observing 
 the above, since the physician thought that he had replaced the 
 organ when he really had exaggerated its abnormality. 
 
 To clear up the diagnosis and ascertain whether you have 
 really replaced the organ, examine the patient in the latero-prone
 
 AFFECTIONS OF THE UTERUS. 205 
 
 position a short while after the attempted replacement. It is a 
 good practice after it is replaced to let the patient lie on the side 
 or in the ventral position for some time until the ligaments con- 
 tract to hold it in position. The best time to correct this form of 
 displacement, as well as any retro-displacement, is just before 
 retiring. If it is replaced at such a time and the patient remains 
 in the ventral or latero-prone position over night, the uterus will 
 become accustomed to the change and remain in the normal posi- 
 tion for a longer length of time. 
 
 Again, if the patient will assume the genu-pectoral position 
 every night just prior to retiring it will help to relieve the con- 
 gestion, lessen the pain and assist in the reduction of the dis- 
 placement. In ordinary office practice it is useless to push the 
 uterus upward by means of the end of the finger unless the parts 
 are prepared to hold it, since as soon as the patient stands erect 
 it drops down into a position as bad as it was formerly. Treat- 
 ments, as are ordinarily given while patient is in dorsal position, 
 are worse than useless; they even doing harm in some cases by 
 constantly irritating the parts. 
 
 After reposition of the organ, it should be raised as high up 
 as possible out of the pelvis. This is accomplished by intro- 
 ducing the right index finger into the anterior fornix, then by ap- 
 proximating the internal and external hand, the uterus can be 
 caught between the two and lifted quite high in the pelvis. Gentle 
 _ massage of the uterus and ligaments is beneficial while in this 
 position. Brandt claims to have cured from 70 per cent, to 80 
 per cent, of all cases, in from two to six weeks by a system of 
 massage of the uterus. The principle of it consists of grasping 
 the uterus, and while the cervix is steadied and held with the 
 internal hand, the fundus and body are thoroughly massaged and 
 kneaded with the external hand. This is repeated as often as
 
 206 DISEASES OF WOMEN. 
 
 the patient can stand it. The treatment is good in chronic ad- 
 hesions of the peritoneum surrounding the uterus. 
 
 Another method of replacement is by means of the wire 
 uterine repositor invented by Dr. Still. (See Fig. 65). It con- 
 
 FJG 65. The wire uterine repositor. 
 
 sists of a wire, bent in such a manner that it will encircle the cer- 
 vix, attached to a handle which is almost at right angles to the 
 larger end or part introduced into the vagina. It is introduced 
 like a speculum, and by inserting the right index finger, the cer- 
 vix can be located and the loop of the instrument adjusted around 
 it. After it is in position, turn the patient on the right side, 
 facing the operator, and gently pull toward you. The "Old 
 Doctor" says, make the umbilicus the objective point, that is, 
 pull toward it. While doing this the air will enter the vagina 
 between the two strands of wire which form the handle, they 
 being slightly separated. On account of the angle formed by 
 the handle and the loop, the handle corresponds in direction to 
 and is parallel with, the uterine axis. By gently pulling the in- 
 strument toward you, the uterus sinks farther down into the 
 loop, and on account of this not only prolapsus, but flexions and 
 versions can be straightened. In its introduction, remember 
 the direction of the vaginal canal, otherwise you may find it diffi- 
 cult to introduce or you may injure the anterior vaginal wall. 
 After the uterus has been lifted up, hold it there for a short time 
 until the venous drainage is well established, then remove instru- 
 ment in the reverse manner of introduction. In withdrawing
 
 AFFECTIONS OF THE UTERUS. 
 
 207 
 
 the instrument be careful to first FREE IT FROM THE CERVIX. To 
 make sure that the cervix is entirely out of the loop, it is best to 
 
 FIG. 66 Showing manner of introduction. Note the direction of loop and handle. 
 
 INTRODUCE THE FINGER, which can be used as a GUIDE in detach- 
 ing the instrument, and in ascertaining whether or not the cer- 
 vix is entirely removed from the loop. If the loop still encircles 
 the cervix at the time of the attempted removal, the cervix will
 
 208 DISEASES OF WOMEN. 
 
 be pulled forward and the uterus thereby displaced. This IN- 
 STRUMENT is TO BE RECOMMENDED ESPECIALLY in the treatment 
 
 FIG. 67. Showing adjustment and movements in replacing prolapsus with wire 
 repositor. The dotted lines show direction handle tikes and effect on uterus. 
 
 of prolapsus, since there is very little danger of injuring any of 
 the parts, the instrument being perfectly smooth.
 
 AFFECTIONS OF THE UTERUS. 209 
 
 The sound is used by some in replacing a prolapsus, but I 
 think it should be avoided if possible, all other methods being 
 employed before resorting to its use. The uterus can be replaced 
 by using the sound, but I believe injuries, producing conditions 
 even worse than the prolapsus, have followed its use, such as 
 puncturing the walls or bruising the endometrium. Reed says, 
 "The old practice of introducing a curved uterine sound and 
 turning it around in the uterine cavity, thus forcing the uterus 
 into position, has been denounced by intelligent gynecologists 
 and abandoned by conservative practitioners." The use of the 
 sound is permissible in partial inversion of the uterus after child- 
 birth, provided a large one is used. In prolapsus, if used at all, 
 the sound should be the largest that can be introduced. In 
 fact a sound smaller than little finger should not be intro- 
 duced into the uterus on the account of the likelihood of punctur- 
 ing the wall. A sound of the above mentioned size, is not likely 
 to injure or perforate the weakened uterine wall. 
 
 The second indication in the treatment of prolapsus is to 
 keep the uterus in position after it is replaced. This can be done 
 in one of two ways. FIRST, by decreasing the weight of the 
 uterus; and SECOND, by strengthening the supports; the causes 
 of the condition being, increased weight of or pressure on the 
 uterus, or a weakening of the SUPPORTS viz., the pelvic floor. 
 
 If the uterus is too heavy and pushes the floor downward, 
 the weight is due to a growth on it or an increase of intra-abdom- 
 inal pressure or a congestion, it is too full of blood. This congestion 
 can be relieved by removing obstructions to the venous drainage. 
 
 This is accomplished in part by correcting a prolapsed dia- 
 phragm. In this condition the lower ribs are involved, drawing 
 the diaphragm down with them. This causes obstruction to 
 the vena cava at the point of passage through it, and the blood 
 
 14
 
 210 DISEASES OF WOMEN. 
 
 is retained in the pelvic organs. Lift up the intestines that have 
 been wedged and packed in the pelvis; this condition interferes 
 with the return circulation. Work over the iliac veins and vena 
 cava to remove any obstruction at those points to the free venous 
 drainage and to restore tone to the walls of the veins; correct any 
 lesions that are found which affect the vaso-motor supply to the 
 uterus. Frequently a lesion is found at the sacrum, or there is a 
 twisted pelvis or slipped vertebra, which interferes with the vaso- 
 motor nerves, shutting off a part of the nerve force, thus causing 
 a relaxation of the vessels supplied by them; the most common 
 and important lesion is the lumbar subluxation by which the 
 uterine vaso-motor centers are disturbed. 
 
 TIGHT CLOTHING, especially constricting bands, should be 
 forbidden, as they interfere with the return flow of blood: the 
 weight of the clothes should be supported from the shoulders by 
 some kind of skirt supporter or suspenders. The patient should 
 be on her feet as little as possible especially at the menstrual 
 period, since the uterus is more congested, hence heavier at that 
 time than at any other. Any occupation involving being on the 
 feet, reaching upward or lifting weights should be given up, at 
 least for a while. As mentioned before, the best time to correct 
 this form of displacement is in the evening, for the treatment can 
 then be followed by rest. This permits of a better circulation 
 through the uterus, from which the ligaments strengthen and 
 CONTRACT and the uterus becomes accustomed to its new posi- 
 tion. 
 
 Attempts have been made to lighten an enlarged uterus, 
 due to hypertrophy of the cervix, by amputating the cervix. 
 This is a method which should not be resorted to since it is pro- 
 ductive of so little good, and in a great many cases of so much 
 harm. It is treating the result of the disease, not the cause.
 
 AFFECTIONS OF THE UTERUS. 211 
 
 THE SUPPORTS of the uterus can be strengthened in several 
 ways. The osteopathic method is to locate the lesion that in- 
 terferes with the nutrient supply to the structures composing the 
 pelvic floor. All NERVES must be FREE FROM PRESSURE or else 
 their function is deranged. This pressure usually occurs at the 
 foramina at which they make their exit. Slips of the vertebrae, 
 however small, will bring pressure on these nerves; either directly 
 by the bone itself, or indirectly bv muscular contraction. This shuts 
 off a part of the nerve force, depriving the muscles of their proper 
 nerve energy, hence loss of tone must follow. 
 
 A DISPLACED SACRUM is really one of the most important of 
 bony lesions, interfering with the nerve supply of the pelvic floor. 
 The form of the displacement that is most frequently found, is a 
 tilting or rotation by which the upper part is thrown forward 
 and the lower part backward ; or else a downward displacement in 
 which it is wedged between the innominata; also the sacrum 
 may be rotated backward until it is almost vertical. The coccyx 
 being movable, is drawn under or forward by the muscles attached 
 to it. The innominate bones are partly dislocated on account of 
 the disturbance of their articulation with the sacrum, and the 
 equilibrium of the pelvis affected. 
 
 In general the abnormality . is usually found in the bony 
 framework, since without a perfect adjustment of these bones, 
 the supports of the uterus can not be permanently strengthened. 
 Remember that each case is different; only a general rule can be 
 given. When these displacements are corrected, nutrition to 
 the pelvic floor will be restored; when this is accomplished the 
 uterus will be, in a great many cases, gradually drawn back into 
 its normal place without the aid of a local treatment. 
 
 In addition to the correction of the lesions as mentioned, 
 CERTAIN EXERCISES are of value in strengthening the pelvic floor,
 
 212 DISEASES OF WOMEN. 
 
 Separation and approximation of the knees against resistance are 
 very good. The forcible adduction is accompanied by prolonged 
 and forcible contraction of the levator ani muscle, especially 
 when the patient at the same time raises the hips. As a result 
 the lumen of the vagina diminishes in size, the uterus is forced 
 upward to a certain degree and later on, after the exercise has 
 been pursued for quite awhile, the uterus is maintained in a better 
 position. Another exercise called the "RESTRAINING MOVEMENT" 
 is of great value in strengthening the pelvic floor. It consists 
 of forcible contraction of the sphincters and levator ani muscles, 
 as in cases of threatened defecation. These exercises develop 
 the muscles that are used. The muscles of the pelvic floor form 
 the main supports of the uterus; hence the condition of these 
 muscles determines the condition of the floor and upon it depends 
 the position of the uterus. 
 
 ARTIFICIAL PERINEAL supports have been used in connection 
 with abdominal supports. By the application of pads suspended 
 from the waist, firm pressure is brought to bear on the weak 
 points of the pelvic floor. This theory will seem plausible at 
 first, but after a second thought it will be seen that it is wrong. 
 As soon as nature realizes that a part is SUPPORTED ARTIFICIALLY, 
 ATROPHY of the natural supports will result, since they would no 
 longer be of use. Instead of increasing the strength of the natural 
 supports, these artificial means both weaken them and prevent 
 their development, and when the practice is once begun, it will 
 be necessary to keep it up, for the supports of the uterus grow 
 weaker the longer their function is subserved. 
 
 ASTRINGENTS applied to the vaginal walls have been used 
 for the purpose of strengthening them and thus support the 
 uterus for a time. Tannin, alum and persulfate of iron have been 
 used, but I fail to see how any curative or permanent value re-
 
 AFFECTONS OF THE UTERUS. 213 
 
 suits from their application. It is applying the treatment to the 
 wrong end of the disorder; the symptom instead of the cause. In 
 order that the supports be strengthened, and this will have to be 
 accomplished if you realize a cure, they must be nourished and 
 strengthened by a natural process, or in other words, there must 
 be a good blood supply. It is admitted by all that there is NO 
 
 NOURISHMENT IN THE ASTRINGENTS MENTIONED, and they do no 
 
 good except that they produce a temporary contraction of the 
 mucous membrane of the vagina, which soon disappears, leaving the 
 walls flabbier than they were before the astringents were used. 
 
 PESSAKIES. The pessary, (from a word meaning an oval 
 shaped stone,) is an instrument placed in the vagina to hold the 
 uterus in position. There are a great many different kinds, both 
 as to shape and material from which they are made. They are 
 constructed so that they will encircle the cervix and by resting 
 on the vaginal wall, principally the posterior, act as an artificial 
 support. The same remarks might be applied to the use of pessa- 
 ries that were made in reference to the use of perineal supports, 
 viz., they weaken the natural supports, and once their use is be- 
 gun, the patient can not very w r ell get along without them. A 
 great many cases come to me for treatment that have been wear- 
 ing a pessary for years. The PESSARY is A FOREIGN BODY. It will 
 be a source of irritation if placed in the genital tract. This irri- 
 tation disturbs the blood supply, producing congestion and in 
 some cases inflammation. In cases in which they have been 
 worn for some time, the patient invariably has METRITIS or VA- 
 GINITIS with a LEUCORRHEAL DISCHARGE, which accompanies a 
 congested condition of the genital tract. The question is often 
 asked me, " should a pessary be removed when a patient comes 
 to an osteopathic physician for treatment?" This is a question 
 that confronts us all and one that is hard in some cases, to answer.
 
 214 DISEASES OF WOMEN. 
 
 Suppose a woman had worn one for years what would be the 
 condition of the vagina and uterus? They would certainly be 
 very weak and flabby, especially the vaginal walls. In such a 
 case I WOULD ADVISE THE REMOVAL of the pessary IF THE PATIENT 
 CAN POSSIBLY DO WITHOUT IT. Its presence hinders the strength- 
 ening of the parts, impairs nutrition and disturbs circulation and 
 should be removed at once if a cure is to be hoped for. However, 
 if the patient on removal of the pessary, has a great deal of pain , 
 locally or reflexly, or by removal, it produces great weakness or 
 nervousness, it should not be left off too abruptly; but gradually 
 get the patient to do without it by having her leave it off as long 
 at a time as she can. 
 
 To the osteopath, the pessary is an unnecessary article and 
 its use not indicated. Even the medical authorities are begin- 
 ning to discard it. Reed, in speaking of their use, says, "so much 
 manifest injury comes from their employment that it has been 
 very largely abandoned." Byford says, "Pessaries are as a rule 
 more harmful than beneficial. The only indication for them is 
 to support the uterus so as to prevent traction upon the tender 
 sacro-uterine ligaments or peritoneal adhesions and a tampon 
 answers the purposes better." In cases in which there is senile 
 atrophy of the vaginal walls, there is prolapsus, but as a rule it 
 does not produce as many and bad symptoms as it does in young 
 subjects. I relieve most of these cases without resorting to the 
 use of the pessary, and if its use is indicated in any kind of case, 
 it certainly would be in this kind. I have treated patients sent 
 to the A. T. Still Infirmary who had worn a pessary so long with- 
 out removing it, that it had buried itself in the vaginal walls and 
 was partly destroyed by the discharges. If one is worn at all 
 it should not be for more than a day or so without removal. 
 
 The STEM PESSARY has been worn for prolapsus. It is so
 
 AFFECTIONS OF THE UTERUS. 215 
 
 arranged that a stem is introduced directly into the cavity of the 
 uterus, and is retained in position by various bands which encircle 
 the waist. This kind of pessary is certainly a BARBAROUS way of 
 exciting endometritis and I am glad to say, this form is fast be- 
 coming obsolete. 
 
 VAGINAL tampons are sometimes used by the osteopaths in 
 cases in which the uterus CAN NOT be kept in place and the dis- 
 placement CAUSES EXTREME PAIN. The common tampon is made 
 by taking a piece of absorbent cotton, or better, lamb's wool, some 
 four inches wide by eight inches long, covered with glycerine and 
 then folded into a wad approximately two inches long by one, to 
 one and one-half inches, in diameter. A string is tied around it 
 by which it may be removed. After lubricating the tampon and 
 fingers with glycerine it is introduced without the use of the specu- 
 lum while the patient is in the Sims or knee-chest position. While 
 the patient is in this position, the shoulders being lower than the 
 hips, the intestines drop downward and the vagina is ballooned. 
 This permits of easy introduction of the tampon and at the same 
 time the uterus is as high as it can be placed ; thus a tampon prop- 
 erly placed will hold the uterus well up in position. One is usually 
 sufficient, although two may be used. If it is a case of retro- 
 flexion it is placed in the posterior fornix. In retro version, two are 
 used; one is placed in the anterior fornix, thereby forcing the cer- 
 vix back, or rather preventing it from going forward, and the other, 
 in the posterior fornix, high up against the body. If the uterus 
 has retained its tone, retroversion can be corrected so long as 
 the tampon is worn, which should not be longer than 36 hours 
 without change. 
 
 Some advise replacing the uterus after, instead of before, 
 the introduction of the tampon. By temporarily supporting the 
 uterus in this way the irritation is lessened and the uterus held
 
 216 DISEASES OF WOMEN. 
 
 in position, thus allowing the blood to drain out. In using the 
 ordinary type of tampon, the one described above, if large enough 
 to distend the orifice of the vagina, and usually it is, CONSIDERABLE 
 DAMAGE MAY RESULT. The repeated downward pressure or traction 
 on the vaginal walls has a tendency to pull the uterus to a lower 
 level in the pelvis, instead of supporting or pushing it higher. 
 
 The CHAIN TAMPON is the best form. It consists of several 
 little tampons tied together at an interval of about four inches. 
 On account of their size and number they can be so placed that 
 pressure is exerted on the cervix or body, or in fact the uterus 
 can really be supported when they are properly placed and pack- 
 ed. In prolapsus several can be packed behind the uterus, one 
 in front of the cervix and one under the end of the cervix. 
 
 Another type, recommended by some, consists of a long 
 narrow roll of lamb's wool or cotton. With such a tampon it is 
 comparatively easy to pack the fornices. It is removed by at- 
 taching a string to it and leaving the end protrude from the va- 
 gina. Although they are rarely resorted to, yet I think they are 
 beneficial in some forms of prolapsus. 
 
 OPERATIVE means are most frequently resorted to at the 
 present time BY SURGEONS, to cure prolapsus of the uterus. One 
 method is to resect a portion of the vaginal walls, stitch the edges 
 together and thus produce a narrowing of the vaginal canal. It 
 also forms scar tissue in the walls which increases their rigidity. 
 This operation generally fails because it does not restore the NOR- 
 MAL ANGLE between the vagina and uterus, and any pressure 
 forcing the uterus downward will RE-DILATE the vaginal canal. 
 The operation is called colporraphy or elytrorraphy. 
 
 Another method is to stitch the uterus to the abdominal 
 wall; the operation being called abdominal fixation or hyster- 
 orraphy. The dangers, if impregnation occurs, are ABORTION,
 
 AFFECTIONS OF THE UTERUS. 217 
 
 HYPEREMESIS and dystocia, all of which result from the adhesion 
 uniting the uterus to the abdominal wall, preventing the uterus 
 from assuming a normal position or size after impregnation. Also 
 the dangers attending any laparotomy accompany ventro-fixa- 
 tion. Other operations have been resorted to, among which is 
 ALEXANDER'S OPERATION for shortening the round ligaments. 
 These operations should, ordinarily, not be resorted to, on account 
 of the risk, the uncertainty of a cure or even of helping the pa- 
 tient, until a fair trial has been given the case by osteopathic 
 methods. 
 
 According to some European statistics, regarding opera- 
 tions for prolapsus, over thirty per cent, of all cases are complete 
 failures, however, the American statistics do not show such a 
 high per cent, of failures. The osteopath has a reputation of 
 PREVENTING OPERATIONS, this being one way by which an im- 
 provement has been made upon surgery. 
 
 ANTEVERSION OF THE UTERUS. Versions and flexions 
 are determined and named from the position of the fundus and 
 its relation to the cervix. When the fundus is forward it is known 
 as an anteflexion or anteversion; when backward, retro version or 
 retroflexion. By VERSION is meant a ROTATION of the uterus on 
 its transverse axis. This axis passes through the uterus at the 
 junction of the cervix and body. A flexion is a bending of the 
 uterus on its long axis, which corresponds to the long diameter of 
 the uterus. ANTEVERSION of the uterus is a condition in which 
 the uterus is turned forward to a pathological degree. 
 
 The uterus normally is in a position of anteversion and slight 
 anteflexion, but if this is increased so that if the ANGLE formed be- 
 tween the vaginal and uterine axes is less than a right angle 
 ACCOMPANIED BY BLADDER SYMPTOMS, it is regarded as pathologi- 
 cal. If the uterus is in a normal position, its axis corresponds to
 
 218 
 
 DISEASES OF WOMEN. 
 
 a line drawn from a point midway between the symphysis pubis 
 and the umbilicus, to the hollow of the sacrum, this line varying 
 
 FIG. t>s. Anteversion of the uterus. 
 
 a trifle in distended or collapsed condition of the bladder. Since 
 the line of demarcation between the normal and abnormal can not 
 be definitely located or fixed, experience has to be relied upon. In
 
 AFFECTIONS OF THE UTERUS. 219 
 
 GENERAL terms, it might be stated that when the long axis of the 
 uterus is found lying across the pelvis, the fundus behind the 
 symphysis and resting on the bladder, and the cervix very high 
 and pointing to the hollow of the sacrum, pathological antever- 
 sion of the uterus exists. 
 
 An anteversion presupposes an increase in size, such as 
 hyperplasia, chronic metritis and subin volution, especially of the 
 fundus of the uterus; while anteflexion indicates atrophy, weak- 
 ening and malnutrition of the entire uterus, but especially at the 
 point of bending, on which account a FLEXION is regarded as a 
 WORSE DISPLACEMENT than a VERSION, and anteversion in par- 
 ticular. In a version the TONICITY OF THE UTERUS is RETAINED 
 to a certain degree, this permitting of a turning instead of a bend- 
 ing, such as we find in flexion . 
 
 In version the direction of the cervix is always changed as 
 well as the direction of the uterine axis. In flexion the cervix is 
 seldom displaced, but the uterine axis is bent on itself. Ante- 
 flexion is often associated with anteversion, the mobility at the 
 angle of flexion usually being increased. 
 
 CAUSES. ANY DISORDER that INCREASES THE WEIGHT of 
 the uterus with retention of tone, unless there is at first a back- 
 ward displacement, will produce anteversion. The most common 
 cause found is INFLAMMATION OF THE UTERUS. Since an inflam- 
 mation is always preceded by a congestion, we must find the 
 cause of the congestion in order to treat it intelligently. This 
 congestion may be produced, as mentioned under the head of 
 prolapsus, by any obstruction to the venous return or vaso-motor 
 disturbances produced by lesions affecting the vasomotor cen- 
 ters of the uterus. In SUBINVOLUTION there is congestion of the 
 uterus, this sometimes producing an anteversion, it depending 
 on the position and degree of subin volution ; but usually a retro-
 
 220 DISEASES OF WOMEN. 
 
 version or prolapsus is the result on account of its position, the 
 uterus being back, as a result of the relaxed condition of the lig- 
 aments following childbirth. PRESSURE on the uterus from 
 above, produces a disturbance in the circulation, increases its 
 weight; this resulting in anteversion in some cases. In case there 
 is a weakened condition of the uterine supports, the uterus, 
 especially the fundus or heavy end will sink to a lower level, if 
 the uterus is in normal or nearly normal position. The writer 
 recently treated a case of this kind. Multipara, patient anemic 
 and very weak. The uterus was very large and if the patient was 
 on her feet for any length of time, the fundus would fall farther 
 forward and downward and would cause considerable distress 
 until replaced. The anterior vaginal wall was very weak, re- 
 sulting in a cystocele, this contributing to a general weakness 
 and helping to cause the displacement. 
 
 NEOPLASMS on the posterior wall of the uterus, force it down 
 into a position of anteversion. Bladder disturbances of all vari- 
 eties complicate such conditions. In such cases the uterus can 
 be pushed up but immediately descends to its former position 
 when pressure is removed. 
 
 During the early months of pregnancy, the uterus is pushed 
 forward and downward on the bladder; however, anteflexion is 
 more common than anteversion. Contraction of the utero-sac- 
 ral ligaments pulls the cervix and lower part of the body higher 
 up into the hollow of the sacrum; and if there is a shortening or 
 contraction of the round ligaments at the same time, anteversion 
 will occur. Adhesions between the anterior wall and bladder 
 will pull the fundus lower, since all scar tissue contracts during 
 its formation. The causes of these adhesions can be traced back 
 to a metritis or inflammation of the peritoneum which as men- 
 tioned above, are the principal causes.
 
 AFFECTIONS OF THE UTERUS. 221 
 
 SYMPTOMS. THERE ARE NO SYMPTOMS CHARACTERISTIC 
 OF ANTEVERSION, PER SB, they being associated with the compli- 
 cations produced by the displacement. As in all displacements, 
 there is a sense of weight, fullness, and of distress in the pelvic 
 cavity. In most cases there is a SETTLING or SINKING OF THE 
 UTERUS, this explaining many of the symptoms attributed to 
 anteversion. Pain is present over the uterus and is reflected to 
 the symphysis and lower lumbar region. The BLADDER is irri- 
 tated by the pressure exerted on it by the uterus and frequent 
 micturition is the result. This pressure, if exerted for any length 
 of time, and especially if there is an inflamed condition of the 
 uterus, may set up a CYSTITIS or inflammation of the bladder. In 
 some cases this is so marked that mucous plugs lodge in the urethra 
 and when expelled, give rise to an INTENSE GRIPING PAIN and 
 followed by marked sediment in the urine, with strong odor and 
 deposit of pus in variable quantities. 
 
 Pressure of the cervix on the posterior wall of the vagina is 
 frequently the cause of a leucorrheal discharge, and the pressure 
 against the rectum results in disturbances such as tenesmus or 
 a painful, irritable state, which is exaggerated during defecation. 
 Further, we may have a train of general symptoms which gen- 
 erally follows any long standing displacement or irritation of the 
 pelvic organs; to wit: DERANGEMENT OF THE DIGESTIVE TRACT 
 
 AND THE NERVOUS SYSTEM. 
 
 DIAGNOSIS. The DIAGNOSIS is made by LOCATING BOTH 
 ENDS of the uterus, there being little trouble in accomplishing 
 this. On local examination, the cervix can be felt high up to ward 
 the hollow of the sacrum. The Sims position is to be preferred, 
 since in this position, examination can be made higher up the 
 vagina than in the dorsal position, it being very difficult or im- 
 possible to reach the cervix with the examining finger while the
 
 222 DISEASES OF WOMEN. 
 
 patient is in the dorsal position. The anterior fornix will be 
 found to be shallow and very much widened, the posterior fornix 
 is decreased or entirely obliterated, this depending on the degree 
 of displacement. A hard body can be plainly felt through the 
 anterior fornix; this is ascertained, by a conjoined manipulation, 
 to be the BODY AND FUNDUS of the uterus. The fundus cannot 
 be palpated through the abdomen unless pushed up by the in- 
 ternal finger, it lying behind the symphysis pubis and on the blad- 
 der. The bladder should be empty when the examination is 
 made, since this will assist in the conjoined manipulation. The 
 uterus will be found enlarged and of firm texture. The mobility 
 should be tested and the presence or absence of adhesions ascer- 
 tained. The POSITION of the CERVIX, it being high and pointing 
 up and back; the ABSENCE of a MARKED CURVE of the anterior 
 wall of the uterus, as is determined by palpation through the 
 anterior fornix, DIAGNOSE ANTEVERSION from anteflexion. If a 
 tumor exists on the anterior wall the diagnosis can be made by 
 locating the fundus by the bimanual method, it being in about its 
 normal position, or if DISPLACED it will be a retro-deviation. In 
 cases in which there is much inflammation which prevents a com- 
 plete vaginal examination, the rectal method enables us to ascer- 
 tain that the uterus is at least not in retroversion and lying back 
 against the rectum. An ANTEVERSION may be MISTAKEN for a 
 congenital RETROFLEXION if only the position of the CERVIX is 
 relied on in making the diagnosis; but a rectal or bimanual ex- 
 amination will clear up the diagnosis. 
 
 TREATMENT. The treatment indicated in most cases, is 
 one directed to RELIEVE the CONGESTION or INFLAMMATION of the 
 uterus, since these conditions are found in the majority of cases, 
 and are the most important of all indications. Sometimes these 
 conditions are causes, but usually are secondary or the result of
 
 AFFECTIONS OF THE UTERUS. 223 
 
 the displacement. If the uterus is turned forward, it certainly 
 will TWIST and put a TENSION on the broad ligaments; the blood 
 vessels being located between the two layers, this tension then 
 forms an obstruction to the circulation. In order TO RELIEVE 
 this twisting, the UTERUS MUST BE REPLACED. 
 
 Replacement is general!}' accomplished by placing the pa- 
 tient in the dorsal position, sometimes elevating the hips by 
 placing the knee or a pillow under the patient; introducing the 
 index finger, or better, two fingers, into the vagina and locating 
 the anterior fornix. By exerting pressure through this, and 
 pulling downward and forward on the cervix, the fundus can be 
 pushed or pried out of the pelvis high enough to be grasped by the 
 external hand; thus having it between the two hands it can be 
 readily pushed into place. This is readily accomplished in a thin 
 subject, but in an obese patient you will have to rely on the va- 
 ginal treatment alone, The uterus can not be felt through the 
 anterior abdominal wall, in patients that are very obese, since 
 with difficulty can it be palpated in this manner in ordinary cases 
 in which the abdominal wall is only slightly thickened. 
 
 In the unmarried in which class of cases a local treatment 
 should be avoided as long as possible, upward manipulation ap- 
 plied to the abdomen at a point just above the symphysis pubis, 
 with the hips elevated, will often correct the displacement with- 
 out a local treatment; but this applies better to an anteflexion 
 than to an ante version. 
 
 The wire uterine repositor invented by Dr. Still can be used 
 to good advrntage in cases of anteversion. By the additional 
 reach obtained by its use, the cervix can be readily manipulated 
 while the patient is in the dorsal position. By depressing the 
 handle slightly downward and forward, the loop having been 
 placed around the cervix, the uterus can be rotated into position. 
 (See Fig. 69.)
 
 224 
 
 DISEASES OF WOMEN. 
 
 A sound has been used for replacing an anteverted uterus, 
 but I think its use is not indicated in any case,on account it being 
 
 FIG. C9. The use of the wire uterine repositor in> antevereion. 1, introduction; 2, ad- 
 justing; 3, first movement; 4, direction of handle when operation ie completed. 
 
 hard to introduce one without injury, and since the uterus can 
 be readily replaced without it. 
 
 Just as soon as it is replaced, the congestion begins to dis- 
 appear and the bladder symptoms leave, and the patient feels a
 
 AFFECTIONS OF THE UTERUS. 225 
 
 great deal better in every respect. If the patient is kept quiet 
 for awhile until the ligaments contract, it will probably remain in 
 place; but, if the patient gets up immediately it will, in most 
 instances, drop forward again with a renewal of the former symp- 
 toms. On account of this I am often asked the question How 
 
 OFTEN WOULD YOU GIVE A LOCAL TREATMENT? This depends Upon 
 
 the amount of pain and nervousness. If the displacement is 
 causing severe pain, replace it; if it falls forward in a few hours, 
 replace it again, but this time put the patient to bed, or at least 
 advise her to keep quiet until the supports are strengthened. 
 Ordinarily I give AS FEW LOCAL TREATMENTS as I can possibly get 
 along with, perhaps one every week or ten days, this depending 
 on the individual case. 
 
 In addition to replacing the uterus the blood may be emptied 
 out of it by work along the veins leading from it. This is similar 
 to the treatment given under prolapsus. In addition, correct the 
 bony displacements found ; they are the predisposing causes. They 
 weaken the supports, impair the nutrition and interfere with the 
 circulation; then the exciting cause, such as a fall or heavy lift,, 
 the more readily results in a displacement. 
 
 The prognosis, in a case of anteversion, depends upon the 
 causes found and the condition and general health of the patient. 
 If the patient is debilitated and very weak, it will take some time 
 to strengthen the part so that the uterus will be held in position 
 because the displacement is the result of a weakening of the sup- 
 ports and is incomplete and gradual. If the patient is strong and 
 there is no loss of tonicity of the tissues, the PROGNOSIS is good, 
 
 SINCE A CURE IS GENERALLY EFFECTED BY A REPLACEMENT of the 
 
 ORGAN. VERSIONS ARE MORE READILY REPLACED, and MORE 
 
 QUICKLY CURED, THAN FLEXIONS. 
 
 ANTEFLEXION OF THE UTERUS. The canal of the nor- 
 
 15
 
 226 DISEASES OF WOMEN. 
 
 mal uterus is straight or slightly curved with the concavity for- 
 ward and downward. When it forms a more decided curve or 
 
 FIG. 70. The wire uterine repositor in position in normal case. 
 
 angle, accompanied by dysmenorrhea and vesical irritation; or if 
 there is an interference with the drainage of the uterine cavity or
 
 AFFECTIONS OF THE UTERUS. 
 
 227 
 
 with impregnation, it is called a PATHOLOGICAL ANTEFLEXION. 
 Dudley says, "Anteflexion is pathological if the mobility at the 
 angle of flexure is increased or diminished or absent." The 
 movements of the uterus are commensurate with the varying 
 
 Fiu. 71. Cervical auteflexion of the uterus. 
 
 quantity of urine in the bladder. If FLEXURE DOES NOT DISAP- 
 PEAR when the bladder fills, but remains constant under all con- 
 ditions, the RIGIDITY MAKES the flexure pathological. This con- 
 dition is more frequently found in the nulliparous than in the
 
 228 
 
 DISEASES OF WOMEN. 
 
 parous, FIRST, because the weight of the intestines and the ab- 
 dominal pressure exerting a force on the posterior wall, tend to 
 exaggerate the normal condition of slight anteflexion; SECOND, in 
 
 FIG. 72. Corporeal anteflexion of the uterus. 
 
 pregnancy the uterus is carried backward and upward, so stretch- 
 ing the round ligaments that it prevents them pulling the uterus
 
 AFFECTIONS OF THE UTERUS. 
 
 229 
 
 back into the position which had existed before pregnancy ; THIRD, 
 on account of the condition of the uterus during involution and 
 the vascular condition of the different ligaments, the uterus re- 
 
 FIG. 73. Cervico-corporeal anteflexion. 
 
 mains in a higher position in the pelvis than it did formerly. 
 
 The usual SEAT OF FLEXION is at the point of junction of the 
 cervix and the body, or it may be at the upper portion of the cer-
 
 230 
 
 DISEASES OF WOMEN. 
 
 vix. The different classifications are based on the point of flex- 
 ion; such as a CORPOREAL, in which the bend is in the body, throw- 
 ing the fundus forward and downward, the cervix remaining in 
 
 FIG. 74. Very marked anteflexion. (Irreducible). 
 
 normal position; cervical, in which the cervix is bent forward; and 
 corporo-cervical, in which both are thrown forward, that is there 
 is a bend in both body and cervix.
 
 AFFECTIONS OF THE UTERUS. 231 
 
 The cervical form may be mistaken, on vaginal examination r 
 for retroversion, since the cervix is in line with the vaginal axis; 
 the DIAGNOSIS must be made by the bimanual or rectal examina- 
 tion. Sometimes there is a congenital form of anteflexion in 
 which the cervix is small, elongated and the os so very much re- 
 duced in size, that it is called the PIN HOLE os. In a majority of 
 all cases both the external and internal ora are small. 
 
 These displacements vary in degree from a slight bending of 
 the uterine canal to that of a COMPLETE SEMICIRCLE, the fundus 
 and cervix almost touching each other. The writer recalls hav- 
 ing several cases in which the uterus was bent into the shape of an 
 inverted "U," the fundus pushing back the anterior vaginal 
 wall. 
 
 The ANTERIOR WALL at the POINT OF FLEXION undergoes a 
 change in which there is a weakening of its muscle fibers. The 
 posterior wall becomes thin on account of the stretching to which 
 it is subjected. When this condition exists for any great length of 
 time, these structural changes tend to become permanent and the 
 displacement is regarded as incurable and is called an irreducible 
 flexion. There is much loss of symmetry, and generally hard- 
 ening of the concave side. This condition of irreducible flex- 
 ion, is found to be most frequent in the CONGENITAL TYPE, due 
 to some accident or cause which resulted in an error in develop- 
 ment. When the fundus is very heavy or large, the displace- 
 ment may become immovable; there usually being adhesions 
 which hold it in that position. In most cases, especially if there 
 is no pelvic inflammation, the uterus is movable and the bend in 
 the uterus can be straightened by pressure against the fundus or 
 by means of a sound. The degrees of flexion vary, and the symp- 
 toms vary, but with the amount of pelvic inflammation and de- 
 gree of development rather than the amount of flexion.
 
 232 DISEASES OF WOMEN. 
 
 CAUSES. The FUNDUS is SUPPORTED by the FALLOPIAN 
 
 TUBES, ROUND LIGAMENTS, BROAD LIGAMENTS, and the body of the 
 
 uterus. The last mentioned support is the most important. On 
 examination of a cadaver the broad ligaments are found to be 
 flaccid, and allow quite a flexion of the uterus to take place be- 
 fore they are made tense. If they were tense cords they would 
 support the uterus, but such not being the case, they only act as 
 stays placed on each side, preventing too much lateral motion. 
 
 In the case of an anteflexion of the acquired type, in which 
 the fundus has dropped forward and downward, there must be 
 some trouble with its supports, that is, with the LOWER PART OF 
 THE BODY of the uterus. This trouble is a softening of the uterine 
 walls from chronic metritis. This weakening is the result of 
 some disturbance of the nutrition of the anterior wall of the uterus. 
 In an inflamed condition of the uterine walls, they are at first firm 
 but afterwards become soft and weak, and the weight to be sup- 
 ported by them is greater on account of the passive congestion. 
 Every strain of the body and every weight lifted forces the uterus 
 farther forward, when once it gets a start in that direction. The walls 
 having lost their elasticity on account of lack of nutrition, are 
 bent more and more until a decided flexion exists. The farther 
 forward it is forced, the more congested the uterus will be on 
 account of the relation of the blood vessels to the broad ligaments. 
 But to get at the primary cause of the congestion we must ex- 
 amine the venous return and the condition of the vaso-motor 
 nerves which are distributed to the pelvic organs. 
 
 A BONY or MUSCULAR lesion affecting the vaso-motor nerves, 
 the usual effect being that of inhibition, serves to dilate the ves- 
 sels innervated by them, thus producing engorgement of the 
 organ. There may be a prolapsed condition of the bowels from 
 various causes, this obstructing the venous blood on its way to the
 
 AFFECTIONS OF THE UTERUS. 233 
 
 heart. Any lesion or obstruction that produces venous conges- 
 tion or chronic inflammation of the uterus, especially in the 
 nulliparous woman, will usually produce a flexion of the uterus 
 on account of the weakening and softening of the uterine walls. 
 
 A change in the tissues composing the uterus takes place; 
 this change is one of atrophy or weakening of them. This, as a 
 result, lessens resistance and the uterus yields to the extraneous 
 pressure. When the uterus is in a normal position and be- 
 comes congested from the causes mentioned above, and as it bends 
 forward of its own weight, the intra-abdominal and pelvic pres- 
 sure, acting on the posterior wall, will gradually exaggerate the 
 condition. 
 
 The CHARACTER OF THE DRESS has a great deal to do with the 
 degree of flexion, or in many, with the causation of it. If too 
 tight, it tends to congest the uterus, thus making the displace- 
 ment worse. A lesion at the sacro-iliac synchondrosis predis- 
 poses to a flexion since it affects the nutrition of the uterus. This 
 effect is partly the result of an interference with the innervation 
 of the sacro-uterine ligaments and partly the result of direct 
 pressure on or disturbance of, the anterior sacral nerves. Other 
 lesions, such as a subluxated innominate or displaced lumbar ver- 
 tebra, are frequently found. These weaken the uterine walls, 
 sometimes shutting off the nutrition of a part, and if this be the 
 anterior wall, anteflexion will result. 
 
 EVERY MUSCLE FIBER HAS A CENTER IN THE SPINAL CORD 
 WHICH CONTROLS ITS TONE. This center is in the ANTERIOR 
 HORNS of the GREY MATTER. The activity of this center deter- 
 mines the nutrition and tone of the muscle fibers. In the case of 
 the uterine muscle fibers, the center is in the lumbar enlargement 
 of the spinal cord and when these cells which comprise the center 
 are mal-nourished the effect is manifest in an atrophied, soft,
 
 234 
 
 DISEASES OF WOMEN. 
 
 uterus. It makes little difference how good the circulation through 
 the uterus is. the blood does not tone it up unless this CENTER is 
 IN GOOD WORKING ORDER. If a man's stomach is diseased, it 
 
 FIG. 75 Anteflexion of uterus from adhesion behind. 
 
 makes LITTLE DIFFERENCE HOW MUCH FOOD is INGESTED, for UN- 
 LESS ASSIMILATION TAKES PLACE HE WILL GRADUALLY STARVE. 
 
 Lesions of the VERTEBRAE affect the blood supply to these cells 
 from which the nerves controlling the uterine muscle fibers get 
 their impulses.
 
 AFFECTIONS OF THE UTERUS. 235 
 
 INFLAMMATORY changes BEHIND the UTERUS, by producing 
 shortening of the sacro-uterine ligaments, often result in ante- 
 flexion. If you will remember the attachment of the ligaments, 
 you can the better understand how a shortening of the same will 
 draw the lower part of the body upward. This shortening of the 
 ligaments is most commonly the result of inflammation; the in- 
 flammation was preceded by a congestion, this congestion re- 
 sulting from several things, such as localized poison as is found 
 in gonorrhea, causing a partial paralysis of the vaso-motor 
 nerves, or from the various bony lesions which affect the pelvis. 
 These thickened bands or ligaments can be felt on local examina- 
 tion and care must be exercised in treating them, for a forcible 
 breaking up of them will often result in an acute peritonitis. 
 
 A FIBROID TUMOR on the fundus or posterior wall will either 
 bend the uterus forward by the increased weight or force it for- 
 ward by the pressure exerted behind the growing tumor. This 
 cause is almost entirely confined to nullipara. In the beginning 
 of pregnancy, that is, up to the third month, the uterus ante- 
 flexes, and forms from its anterior position and shape, one of the 
 best of the early signs of pregnancy, the uterus being found to 
 resemble in shape an inverted jug. 
 
 UNEQUAL INVOLUTION of the uterus during the puerperium 
 is a cause of the acquired form of anteflexion. The placental 
 site, being on the posterior wall, prevents it from involuting so 
 rapidly as the anterior wall. 
 
 UNEQUAL DEVELOPMENT is the cause of the CONGENITAL 
 form. Since the uterus lies dormant up to the age of puberty, 
 and at that time undergoes a wonderful developmental change, 
 any interference with its nutrition, such as directing the nerve 
 force by overwork through another channel, will result in a non-, 
 or imperfectly developed organ. This causes many cases of the
 
 236 DISEASES OF WOMEN. 
 
 so-called infantile uterus, which can be traced back to some ac- 
 cident at puberty. In such cases is found the worst type of ante- 
 flexion. The menstrual pains are more severe is this form of ante- 
 flexion than in any other form. The fornices are shallow, the os 
 small, the vagina long and the uterus high. The cervix in most 
 cases is somewhat elongated and situated in the long axis of the 
 vagina; such conditions are most frequent and best marked in 
 the obese. If pregnancy ever does take place the labor is very 
 hard. 
 
 In other cases there is a CONGENITAL PREDISPOSITION TO 
 FLEXION; that is, the girl is born with a weakened condition of the 
 uterus at the point of junction of the body and cervix; then the 
 posture, mode of dress and occupation, all of which produce 
 pressure on the upper and back part of the uterus, force it down 
 in anteflexion. 
 
 In still other cases the sacro-uterine ligaments remain short 
 and hold the uterus high in the pelvis as it is during infancy. 
 
 THE SYMPTOMS. The symptoms of anteflexion of the 
 uterus depend upon its IMPINGEMENT on itself and neighboring 
 structures ; narrowing or STENOSIS of the uterine canal ; amount of 
 INFLAMMATION in and around the uterine walls, and VARIOUS RE- 
 FLEX DISTURBANCES affecting organs that are weakened by le- 
 sions. The organs and structures impinged on are the bladder and 
 the anterior vaginal walls, the pressure, exerted like that in ante- 
 version, producing frequent micturition and sometimes a conges- 
 tion or inflammation of the mucous lining of the bladder, result- 
 ing if severe enough in some cases in cystitis. The frequent mic- 
 turition is due not so much to the mechanical pressure exerted on 
 the bladder, as to the inflammation of the uterus. The greater 
 the degree of inflammation the more frequent the micturition. 
 Another point in favor of this theory is that frequent micturition
 
 AFFECTIONS OF THE UTERUS. 237 
 
 occurs in many cases of retro-displacements when metritis exists 
 partly as a result of the inflammation extending to the bladder 
 and partly from traction on the bladder. 
 
 Pain occurs when the bladder is distended and sometimes the 
 sensation of distress follows immediately after evacuation of the 
 bladder. This peculiar griping pain is due to an effort on the part 
 of the bladder to expel an imaginary foreign body. The irrita- 
 tion is the result of the inflamed uterus pressing on the bladder. 
 Impulses arising from this pressure reach the micturition center, 
 thus resulting in an attempted evacuation; the center mistaking 
 the impulses for the normal impulses which are formed when the 
 bladder is distended. Sometimes the contraction of the utero- 
 sacral ligaments draws the lower part of the body upward and 
 backward, thus putting on a tension the vesico-vaginal walls, 
 which condition can be ascertained by local vaginal examination. 
 
 Impingement on the walls of the uterus at the point of flexion 
 affects circulation, nutrition and secretion, and finally results in 
 atrophy of the wall. This wall becomes weaker and thinner, as 
 regards normal uterine tissue, but there is a gradual increase in 
 deposit of fibrous material the longer the pressure exists, and 
 finally reaches such a degenerative stage that the displacement 
 becomes very hard to correct. 
 
 The flexion also NARROWS or causes a complete stenosis of 
 the uterine and cervical canals. The secretions will then be re- 
 tained, which undergoing changes cause irritation of the en- 
 dometrium. Abortion follows such conditions if the constric- 
 tion is not complete enough to prevent impregnation. 
 
 Endometritis frequently complicates \\ith its attending pains 
 and reflexes. The collapse or obstruction of the uterine canal 
 will prevent or interfere with the expulsion of the menstrual dis- 
 charge, giving rise to dysmenorrhea or painful menstruation. In
 
 238 DISEASES OF WOMEN. 
 
 this kind of dysmenorrhea the pain ceases as soon as the flow 
 starts, but it is rare to get a typical case, for endometritis is pres- 
 ent in most of the cases. It also TAKES MORE force, that is, 
 HARDER UTERINE contractions to expel the menstrual fluid up 
 and around a curve, thus the pain. In anteflexion, the fundus is 
 low and the blood accumulates in the cavity at this point, which 
 is lower than the curved portion. If endometritis complicates 
 the flexion the pain will be severe, since the contraction of the 
 muscle involving an inflamed area will certainly be productive of 
 pain of the worst type. I am inclined to the belief that in most 
 cases of dysmenorrhea, THE INFLAMMATION is THE REAL CAUSE OF 
 THE PAINS. In other cases the pain is due to strong uterine con- 
 tractions. If the blood is prevented from escaping it will coagu- 
 late, and in order to force the coagula through a narrow canal the 
 uterus has to GO INTO LABOR, and THE UTERINE CONTRACTIONS 
 SIMULATE LABOR PAINS. Inflammation of the endometrium and 
 walls permits coagulation of the retained menstrual flow. 
 
 If there is little inflammation the pain will be in proportion 
 to the amount of it and from this we will conclude that the dys- 
 menorrhea accompanying anteflexion, is mostly due to the in- 
 flammation and only is partly due to a narrowing of the canal. 
 The writer has seen cases in which upon examination with the 
 speculum during menstruation, CLOTS WERE FORCED OUT OF AN 
 
 APPARENTLY VERY SMALL OS UNACCOMPANIED BY PAIN, there being 
 
 no inflammation of the uterus. Also other patients likewise ex- 
 amined, suffered great pain on the expulsion of coagula from a 
 patulous os. If the patient is married and has anteflexion, 
 usually there is sterility. The spermatozoa are either unable to 
 gain entrance into the uterine cavity on account of its oblitera- 
 tion from flexion, or else the diseased condition prevents them, 
 after impregnation has occurred, from becoming attached to the
 
 AFFECTIONS OF THE UTERUS. 239 
 
 uterine wall. Since the leucorrheal discharge from a diseased 
 uterus usually is acid, it counteracts the alkaline spermatozoa. 
 If patients suffering from anteflexion become pregnant there is 
 almost sure to be hyperemesis. This can be relieved in part by 
 straightening the curve, which is best done by a local digital 
 treatment. In marked types of anteflexion, the effort necessary 
 to raise the uterus out of the pelvis often gives rise to uterine con- 
 tractions SEVERE ENOUGH to expel the contents of the uterus, this 
 constituting a common cause of abortion. On the other hand 
 pregnancy is one of the the surest cures for anteflexion if the pa- 
 tient carries to term. Anteflexion, if chronic, is accompanied by 
 the usual reflexes, such as backache, headache, or in some, gastric 
 disturbances and functional heart trouble. These reflexes rather 
 depend upon the amount of inflammation present, than upon the 
 kind or degree of the flexion. 
 
 DIAGNOSIS. The diagnosis of anteflexion of the uterus is 
 made by a vaginal and bimanual examination. As the finger 
 passes into the vagina and touches the cervix nothing abnormal, 
 if it is a typical case, will be noticed; the direction of the cervix 
 not usually being changed in an anteflexion. In some cases the 
 anterior lip will be elongated or rather, the posterior lip of the cer- 
 vix will be shortened, on account of the traction exerted on the 
 posterior uterine wall, this giving the anterior lip the appearance 
 of being elongated, or of a small growth upon it. As the finger 
 sweeps along the anterior wall of the uterus at a point just above 
 the os internum, a protuberance will be met with, which is the 
 body or fundus of the uterus pressing against the bladder and 
 the anterior vaginal wall. By outlining the anterior wall of the 
 uterus with the examining finger in the anterior fornix of the 
 vagina, a MARKED CONCAVITY, CURVE OR ANGLE can be outlined. 
 When this curve or angle of flexion is discovered and there is no
 
 240 DISEASES OF WOMEN. 
 
 tumor, the DIAGNOSIS is POSITIVE. Keeping the finger upon the 
 mass, the other hand should be placed upon the abdomen just 
 above the symphysis pubis and made to compress the abdominal 
 wall so that the two hands will be approximated. By this means 
 the shape, size and sensitiveness of the body can be ascertained. 
 
 To differentiate the body felt in the anterior fornix from a 
 fibroid tumor, consider the form of menstrual disturbance and by 
 the bimanual method outline the fundus, which would be posterior 
 if a tumor were present. Sometimes the use of a sound is advo- 
 cated. If the sound, on introduction, meets with resistance it is 
 diagnosed as a flexion if the other symptoms are present; but if 
 the sound meets with no resistance and the uterine cavity is elonga- 
 gated, it is probably a fibroid tumor. There is always danger in 
 the use of a sound for diagnostic purposes, since one is very likely 
 to injure the uterine wall, not knowing the direction of the canal. 
 
 The POSITION of the CERVIX will DIAGNOSE ANTEVERSION 
 from ANTEFLEXION since in anteversion it is changed in direction, 
 while in anteflexion it usually is not. In case it is changed, it is 
 thrown forward rather than backward. If in doubt after making 
 the bimanual examination, make a rectal examination, since by 
 this it can be ascertained that the uterus is not retro-deviated, 
 for nothing but the cervix can be felt through the anterior rectal 
 wall. On vaginal examination, especially in congenital cases, cerv- 
 ical anteflexion may be mistaken for retro version ; but the diagnosis 
 is cleared up by the bimanual method and by feeling the angle of 
 flexion. Quite often there is an anteflexion with a retro version 
 or retroposition. This is ascertained by finding the cervix in 
 line with the vaginal axis, the body in retroposition and by feel- 
 ing the curve or angle in the anterior uterine wall. The ante- 
 flexion, if primary, becomes an irreducible one and then while in 
 this state, the uterus is forced backward by the usual causes, of
 
 AFFECTIONS OF THE UTERUS. 
 
 241 
 
 retro version. The uterus remains back and retains its curve, 
 hence the apparently paradoxical condition. The symptoms and 
 treatment of this condition are the same as for simple retroversion, 
 except in cases of obstructive dysmenorrhea. In such cases the 
 uterine canal ought to be straightened or dilated. 
 
 PROGNOSIS. The prognosis of an anteflexion, as to straight- 
 ening the canal, is UNFAVORABLE, but relief can be promised in 
 most cases. The ability to straighten the curve depends on the 
 
 FIG. 76. Retroversiou with antefleetlon. 
 (Byford) 
 
 amount of fibrous tissue deposited at the angle of flexion. Since 
 the inflammation and weakening of the wall at the point of flexion 
 is the real cause of the disturbances, the flexure in itself need 
 create no anxiety, for it is not of great importance except that it 
 may cause sterility on account of obstruction of the uterine canal. 
 TREATMENT. The points indicated for the treatment of 
 anteflexion are first, reduction of the inflammation; second, 
 strengthening of the uterine walls; and third, opening up of the 
 uterine canal by reducing the. flexion. It must be borne in mind 
 
 16
 
 242 DISEASES OF WOMEN. 
 
 that flexions are unlike versions in respect to the rapidity in which 
 they are formed. VERSIONS may OCCUR SUDDENLY from a fall or 
 violent strain, while FLEXIONS OCCUR GRADUALLY from a weaken- 
 ing of the uterine walls or pressure long continued. Therefore 
 versions are susceptible of immediate relief, while as a rule, flex- 
 ions are not, since they are the consequences of influences long 
 kept up. 
 
 The reduction of the metritis accompanying anteflexion is 
 accomplished by the correction of the causes producing it. THE 
 BONY LESIONS found, must be reduced or else the local treatments 
 will do little if any good. These lesions affect nutrition of the 
 walls, and in order to cure the flexion the walls must be strength- 
 ened. These lesions also affect the uterine circulation, thus to 
 reduce the inflammatory condition the vascular supply must be 
 made normal, which is done in part, by correcting the bony le- 
 sions found especially in the lumbar region. 
 
 The uterine walls are straightened by repeated replacement 
 of the organ. The pressure of a flexion increases the atrophy and 
 weakness of the wall, and must be straightened out before a com- 
 plete cure can be attained. 
 
 Replacement is effected by placing the patient in the dorsal 
 position, introducing one or two fingers into the vagina, and 
 pressing upward on the anterior fornix, through which the body 
 and fundus can be felt. After it has been forced up as high as 
 possible the fundus can then be grasped by the external hand. 
 When this is done, and the uterus firmly caught, it can be bent 
 into position very readily. The objection to this is the diffi- 
 culty in obese people, of being able to feel the uterus through the 
 abdominal wall. In such cases the physician will have to rely 
 upon the pressure exerted by the vaginal finger, and in most 
 ases it can be replaced in this way. It is best to have the hips
 
 AFFECTIONS OF THE UTERUS. 243 
 
 elevated while replacing the organ, and after the displacement is 
 corrected the patient should rest for some time in the dorsal posi- 
 tion. 
 
 The OBSTACLES to replacement are adhesions, inflammation 
 of and around the uterus and structural changes in the uterus, 
 usually most common at the point of flexion. 
 
 Sometimes ANTEFLEXION can be CORRECTED by external 
 ABDOMINAL MANIPULATION. I have taken cases of dysmenorrhea, 
 dependent upon an anteflexion, and by elevating the hips and 
 working deeply over the abdomen with an upward motion, I have 
 been able to straighten the uterine canal, thereby starting the 
 flow and relieving the pain. I make it a practice of giving this 
 treatment first, in cases of anteflexion in nullipara, since it re- 
 moves the pressure exerted by the intestines and certainly TENDS 
 to correct the displacement, and in many it is entirely corrected 
 in this way. 
 
 If it is impossible to replace the organ by these means, resort is 
 made to the use of a sound. This method is mentioned more for 
 the sake of completeness than as an important therapeutical 
 measure. The cases in which the use of a sound is indicated are 
 very rare. The patient should be placed in the Sims position. 
 After warming, lubricating and disinfecting the sound, it can be 
 introduced in the manner previously described. It is a painful 
 operation and should be done as slowly and gently as possible. 
 Be careful to first diagnose the position of the uterus and then use 
 no force in the introduction of the sound. Schultze says, "The 
 uterus, when normally flexible and movable, slips over the instru- 
 ment if the latter is carefully introduced, even though the direc- 
 tion given to it may differ very materially from that in which the 
 uterus itself was previously lying." But if the uterus is in any 
 way fixed, the sound can not be passed as Schultze describes un-
 
 244 DISEASES OF WOMEN. 
 
 less its point be carried forward in the direction of the cavity; 
 and even after the shape and position of the uterus have been ex- 
 actly ascertained, it is often very difficult to bend the sound into 
 such a shape that it can be introduced into the cavity. On ac- 
 account of the inflamed condition of the endometrium, any force 
 USED will INJURE the endometrium and bring on pain and in 
 many cases hemorrhage. Unless the sound is clean it may carry 
 disease to this weakened endometrium and set up a more severe 
 endometritis. After the sound is in position the uterus can be 
 moved at will unless adhesions bind it down. Be careful not to 
 use much force since you have a greater lever power than you 
 imagine. Ordinarily by simply bringing the handle forward, 
 that is, towards the patient's limbs, the uterus can be forced into 
 place. After this is done it should be carefully withdrawn and 
 the patient left either in the latero-prone or dorsal position for 
 some time. It produces quite a shock to the nervous system 
 and should not be repeated within several days, even if 
 found that the uterus has become displaced again. Also the 
 sound should not be used after the tenth day following menstrua- 
 tion if it can be otherwise avoided, since it is apt to bring on the 
 menses. Frequently a leucorrheal discharge will follow the use 
 of a sound, but this only lasts for a short time and is due to the 
 disturbance of the tender endometrium or a straightening of the 
 uterine canal, thus allowing the retained secretions to escape. 
 
 The use of a stem pessary has been resorted to by so me, but I 
 think their use is productive of more harm than good. This pessary 
 when used is a source of irritation to the uterus, increases danger 
 of infection, and instead of doing good, very frequently leads to a 
 more serious metritis. 
 
 When anteflexion is irreducible and dysmenorrhea and 
 sterility exist on account of the obstruction to the uterine canal,
 
 AFFECTIONS OF THE UTERUS. 245 
 
 surgeons have made an artificial opening by various operations, 
 such as an excision of the posterior lip, lateral incision, amputa- 
 tion of the entire cervix, etc. The writer has seen many cases in 
 which a longitudinal incision has been made the entire extent of 
 the vaginal portion of the cervix, and invariably the patient was 
 not even relieved of the dysmenorrhea. Amputation of the cer- 
 vix has given a higher per cent, of relief than the above mention- 
 ed operation, although some cases have been made a hundred 
 times worse by such an operation. Operations should never be 
 resorted to until it is evident, after careful and thorough trial, 
 that the case can not otherwise be cured or relieved, and even 
 then they are experiments in most cases. 
 
 RETROFLEXION OF THE UTERUS. Retroflexion of the 
 uterus is a displacement in which it is bent backward on itself 
 in contra-distinction to anteflexion,in which it is bent forward on 
 itself. Retroflexion is preceded in most cases by retroversion, 
 that is, THE UTERUS is FIRST TURNED BACKWARD, then the intra- 
 abdominal and pelvic pressure is exerted against the anterior 
 wall, thus bending it further backward. (See Fig. 77.) 
 
 This displacement with the accompanying complex train of 
 symptoms is ONE OF THE MOST IMPORTANT that comes to the gyne- 
 cologist. Since retroversion invariably precedes it, there is to con- 
 tend with, the double displacement with all the symptoms of each. 
 It occurs less frequently than anteflexion; first on account of the 
 natural anterior obliquity favoring the anteflexion; and second, 
 the retroflexion is more thoroughly guarded against by the liga- 
 mentous supports ; the round ligaments, running from the horns of 
 the uterus to the vulva, tending very decidedly to prevent a back- 
 ward bending. They not only do this, but if softening of the 
 walls from inflammation of the uterus occurs, they would natural- 
 ly draw it forward; yet, if the softening is the result of chronic
 
 246 DISEASES OF WOMEN. 
 
 metritis, the uterus descends and the round ligaments, be ing com- 
 posed of structure similar to the uterus, soften and stretch. 
 
 CAUSES. As in anteflexion, we find SOFTENING OF THE 
 wall from metritis a very common cause. The indications of the 
 chronic metritis are general pelvic tenderness and adhesions 
 which limit the mobility of the uterus. These adhesions are 
 often threadlike and friable while in the worst types they are ex- 
 tensive, thick and tough. The inflammation extends to the 
 round ligaments whose function it is to hold the uterus in normal 
 ante version. This weakens them, and by their relaxation, the 
 uterus is BENT backward by a very slight force exerted from the 
 front or above. If the sacro-uterine ligaments are relaxed and 
 the cervix is allowed to go forward, which condition is necessary in 
 backward displacements, retroversion will complicate the retro- 
 flexion , and this is the condition in a large per cent, of all cases of 
 retroflexion. Schultze says that the cause of ninety per cent, of 
 cases is "RELAXATION of the SACRO-UTERINE LIGAMENTS due to 
 constipation; general weakness with relaxation of all the pelvic 
 cellular tissues; but particularly to post partum, pathological 
 conditions, such as a lacerated cervix and vaginal fornices, getting 
 up too soon, etc." This metritis, as has been mentioned, is the 
 result of a disturbed blood supply. Bony lesions, which affect 
 the centers that control the blood supply of the uterus, cause a 
 venous stagnation, on account of which the blood undergoes 
 changes, poisonous materials collect which result in an attempt on 
 the part of the organism to rid itself of this poison, which attempt 
 we call inflammation. No constant particular lesion is found; but 
 there usually exists a subluxation at the sacrum, innominata, or 
 of the lumbar vertbrae. The vaso-motor centers for the internal 
 genitalia, according to Quain, are in the lumbar spinal cord. The 
 impulses travel over the lumbar cerebro-spinal nerves or white
 
 AFFECTIONS OF THE UTERUS. 
 
 247 
 
 rami to the ganglia, thence to the uterus by way of the aortic and 
 hypogastric plexuses to the pelvic, thence to the uterine plexus.. 
 A curvature in the lumbar region must of necessity, affect the.- 
 
 FIG. 77. Retroflexion preceded by retroverRion. The common form. 
 
 circulation of blood through the uterus, unless it develops so 
 slowly that compensation can take place. 
 
 Again, these lesions affect the MOTOR NERVE SUPPLY to the 
 muscle fibers composing the uterus. A muscle fiber to be nor- 
 mal, must have a certain amount of nerve force traveling to it,
 
 248 
 
 DISEASES OF WOMEN. 
 
 giving it tone. When this nerve force is increased in amount, the 
 uterus contracts as in parturition and menstruation. When 
 this nerve force is lessened, the muscle fibers of the uterus relax, 
 
 FIG. 78 Extreme retroflexion with softening of wall at point of 
 flexure. (Irrexlucible). 
 
 weaken and atrophy. This is illustrated best in the cases of 
 atonic paralysis. 
 
 This relaxation of the tissues of the uterus is the important 
 cause of flexion. The center for the tone of the muscles of the
 
 AFFECTIONS OF THE UTERUS. 249 
 
 uterus is in the anterior horns of the grey matter of the lumbar 
 spinal cord. The above mentioned bony lesions affect these cen- 
 ters by interfering with their nutrition and by affecting the 
 nerves at their exit from the spinal canal. 
 
 After the uterine walls have been weakened by these lesions 
 which shut off the nutrition, then the exciting cause, such as ex- 
 ertion, a fall backward when the bladder is distended, more 
 readily produces a displacement, first, a retro version and soon a 
 retroflexion if the walls are weak. 
 
 Retroflexion is RARELY CONGENITAL, in which respect it con- 
 trasts with anteflexion. It is frequent in multipara (rare in 
 nullipara) because the cause is especially related to the puerperal 
 state. During the puerperium the walls are large, vascular and 
 very soft. The ligaments and all the supports are weakened on 
 account of not having, in such a short time, recovered their tone. 
 If the bladder is much distended it will force the uterus backward, 
 and if this is frequently repeated, and the patient lies on her back, 
 the uterus will be forced back and perhaps remain permanently 
 in that position. 
 
 On examination of the patient shortly after her confine- 
 ment, we sometimes find that the uterus is lying back in the pelvis. 
 The intra-abdominal pressure which, when the uterus is in the 
 normal position is exerted on the posterior wall, now comes to 
 act on the anterior wall, forcing the fundus backward and down- 
 ward. Each straining effort forces it a little further until by 
 degrees it is retroflexed. 
 
 The practice of putting on a tight abdominal binder after 
 confinement tends to force the uterus downward into a cramped 
 position, and later on it is forced backward, and this is especially 
 true if the patient lies a great deal in the dorsal position during 
 the puerperium. The uterus after labor remains low in the pelvis
 
 250 DISEASES OF WOMEN. 
 
 for about twenty-four hours. AFTER THAT TIME it SHOULD RISE 
 AS HIGH AS THE UMBILICUS. If the uterus is normal in tone it 
 will become straightened out unless held down by a "binder," 
 If the bandage is applied, or if the uterus is very weak as is often 
 the case in tedious labors, it remains in a collapsed, crumpled con- 
 dition, partly out but mostly in the true pelvic cavity. This 
 condition interferes with drainage, HENCE THE GREAT LIABILITY 
 TO PUERPERAL fever. The writer always advises the giving of a 
 "LIFTING UP" ABDOMINAL TREATMENT, if the uterus fails to 
 ascend, for the purpose of straightening the uterine canal. This 
 is best accomplished by placing the patient on the side and mak- 
 ing deep pressure just above the symphysis pubis and then carry- 
 ing the hand backward and upward, thus lifting the intestines 
 and partly straightening the uterus; it usually being in a position 
 of anteflexion soon after labor is completed. The author's rule in 
 obstetric work, is to establish FREE DRAINAGE OF THE LOCHIA, 
 thus preventing childbed FEVER. If drainage is good it is well nigh 
 impossible for a fever to occur if any care whatever is taken. 
 
 A FIBROID tumor on the anterior wall may, by its growth 
 force the uterus backward, thus producing a retroflexion. Un- 
 equal involution of the uterus, when the placental site is on the 
 anterior wall, causes the posterior wall to contract faster than the 
 anterior, thus drawing the upper part backward. 
 
 ADHESIONS may draw the fundus backward or laterally, 
 while the cervix is fixed by other adhesions. This results in a bad 
 form of retroflexion. The adhesions usually follow metritis or a 
 perimetritis, and the treatment should be directed to absorb 
 rather than break them up. 
 
 After considering all these causes the most important is THE 
 METRITIS, which softens and enlarges the uterine walls. To the 
 osteopath this usually means that there is some derangement of
 
 AFFECTIONS OF THE UTERUS. 251 
 
 the bony framework which encloses the pelvic organs, shutting off 
 some of the nutrition or nerve force that should be transmitted 
 through the numerous foramina to the pelvic organs. 
 
 SYMPTOMS. The symptoms of retroflexion may be arranged 
 in three groups ; the FIRST, including those which are more or less 
 continuous; the SECOND, those that are referred to the menstrual 
 period; and THIRD, those connected with the function of repro- 
 duction. 
 
 Backache is one of the common symptoms attending any 
 displacement, but especially retroflexion. It may be a dull con- 
 stant ache or it may be an actual pain, which is aggravated by 
 muscular action and at the menstrual period. The patient usual- 
 ly describing it in this way: "My back feels like it is broken or 
 unjoin ted in the small of the back or at the waist line." This is 
 WORSE IN THE EVENING if the patient has been on her feet during 
 most of the day. There is a weakness or a distinct PAIN between 
 the SCAPULAE which is increased by exercise or fatigue. Finally 
 the patient tells you of a drawing sensation in the neck ; the HEAD 
 has a tendency to RETRACT; the EYEBALLS become TENDER, or in 
 some cases there is a distinct ACHE and there is the usual VER- 
 TICAL HEADACHE. 
 
 Sciatica in its worse form is often produced by retroflexion 
 of the uterus. This is partly the result of pressure on the sacral 
 nerves and partly due to the inflammation of the uterus extend- 
 ing to the nerve. The writer has cured cases of synovitis of the 
 knee by correcting a retroflexed uterus. Various other types of 
 neuritis and neuralgia of the lower limbs result from retro- 
 flexion. 
 
 Metritis with its symptoms of heaviness and distress in the 
 pelvis, is present. Tenderness is obtained by pressure over the 
 uterus, that is, at a point just above the symphysis pubis. Any
 
 252 DISEASES OF WOMEN. 
 
 condition producing MOVEMENT of the uterus, such as a digital 
 examination, coition, or jarring of the body, causes pain in the 
 uterus. 
 
 CHRONIC PERITONITIS with its adhesions and exudates, ac- 
 companies the metritis and fixes the uterus in its abnormal posi- 
 tion. Endometritis is present with its disturbing secretions. 
 DYSPAREUNIA occurs if the inflammation is very marked. PAIN- 
 FUL or DIFFICULT DEFECATION results from either the inflamed 
 condition of the uterus, or the pressure of the uterus against the 
 rectum. This gives the patient the sensation of a loaded bowel, 
 and the repeated attempts to empty it, are often accompanied 
 by tenesmus. Passage of the bowel contents through, and con- 
 traction of the sphincter muscles around an inflamed and sensi- 
 tive zone, are necessarily accompanied by considerable pain. In 
 case that constipation complicates retroflexion, I think it due, in 
 most cases, rather to the RELAXED CONDITION OF THE SPHINCTER 
 MUSCLE and mucous lining of the rectum, than to any mechanical 
 obstruction produced by the displaced uterus. The pressure of 
 the uterus deadens the sensation in the bowel as does constant 
 pressure on any sensory nerve. 
 
 There is a weak, flabby condition of the sphincter muscles 
 in chronic cases and the MUCOUS MEMBRANE PROLAPSES. On 
 making a rectal examination in these kind of cases, the finger will 
 meet with a blind obstruction, the lumen of the bowel being very 
 hard to discover. I have examined cases, in which the internal 
 sphincters had prolapsed so that they approached the anal open- 
 ing, thus occluding the bowel at that point. 
 
 LEUCORRHEA accompanies this form of displaced uterus, if 
 there is an existing endometritis. The BLOOD SUPPLY of the 
 mucous and other glands is impaired in quality, it being venous 
 in character. If there jWere increased arterial supply, the physiol-
 
 AFFECTIONS OF THE UTERUS. 253 
 
 ogical secretions would be increased; but an increased amount of 
 venous blood produces a pathological secretion or leucorrhea. 
 If the case is chronic and the uterine and vaginal walls are soften- 
 ed, leucorrhea is a constant symptom, but if it is a recent case it is 
 usually absent. 
 
 DYSMENORRHEA, though not so common as in anteflexion, 
 is an important symptom of retroflexion, and is due to the metri- 
 tis or inflammation of the uterus, or to the obstruction at the 
 point of flexion. In some cases it is due to both. As mentioned 
 under anteflexion, there would be very little pain if no inflamma- 
 tion accompanied the narrowed condition of the uterine canal. 
 When there is narrowing, obstruction and an inflamed condition, 
 great pain is experienced when the uterus contracts in its effort 
 to overcome the obstruction to the exit of the menstrual flow. 
 This dysmenorrhea is not so marked as that found in anteflexion ; 
 probably on account of the patulous condition of the os uteri from 
 pregnancy, since retroflexion is most commonly found in multi- 
 para. 
 
 If there is marked congestion, MENORRHAGIA will be a symp- 
 tom of this displacement. On account of the obstruction of the 
 return flow of blood, the uterus becomes engorged and the mens- 
 trual flow is a safety valve whereby the uterus can rid itself of 
 this extra amount of blood. 
 
 STERILITY is sometimes found, and is due to an altered con- 
 dition of the os and cervix; increased mucous secretion; obstruc- 
 tion of the Fallopian tubes, or prolapsus of the ovaries. If the 
 fundus is bent backward very far, the tubes and ovaries must be 
 altered in position, sometimes to such an extent that there is 
 suspension or destruction of their function. Frequently the 
 patient will tell you that she had a child several years ago, and 
 after that she suffered with leucorrhea, pain in the back, irregu-
 
 254 DISEASES OF WOMEN. 
 
 lar menstruation, and has never conceived again. In such cases 
 a retroflexion is commonly found. After conception has taken 
 place in such cases there is a further risk of abortion. Concep- 
 tion may take place in a retroverted uterus WHICH MAY RIGHT 
 ITSELF as soon as the fetus begins to grow and push the fundus 
 out of the pelvis, which is about the third month. If the uterus 
 does not right itself, or if the mucous membrane is in a pathologi- 
 cal condition which prevents the ovum from being firmly 
 attached, abortion will occur. 
 
 The SIZE of the uterus, that is, the length of the body and 
 size of the cavity, are increased in retroflexion, the cavity meas- 
 uring about three inches in length. The posterior wall at the 
 point of flexion is thin and atrophied. The abdominal pressure 
 acting on the anterior wall, forces the fundus lower into the pouch 
 of Douglas; sometimes it rests directly on its floor. The bladder 
 is not always disturbed, but lacks the pressure of the uterus on it, 
 this sometimes causing trouble. 
 
 The ureters are often compressed, this giving rise to renal 
 trouble or a pain resembling the passage of a renal calculus. 
 
 The nerves supplying the lower limbs, may be affected by 
 the pressure of the retroflexed uterus and give rise to PAINS IN 
 THE LOWER EXTREMITIES. There may be only a sense of weak- 
 ness with no particular pain, the patient complaining of feeling 
 tired in the limbs after a slight exertion or else they remain cold 
 a great deal of the time. 
 
 ABDOMINAL pain, neuralgias in different parts of the body, 
 nervous dyspepsia and neurasthenia are usually present. Hys- 
 teria in all its peculiar and varied forms, sometimes attends this 
 condition. 
 
 TENDERNESS is found along the sacro-iliac SYNCHONDROSES, 
 sometimes there is a knotty feeling in the muscles and lymphatics
 
 AFFECTIONS OF THE UTERUS. 255 
 
 at this point. The fifth lumbar is frequently found to be tender 
 on palpation. The sacrum, in some cases, will be found to be 
 prominent, indicating a TURNING at the sacro-iliac junction. 
 Since the inferior hypogastric plexuses are located on either side 
 of the uterus, the backward displacement will certainly disturb 
 them in some way; by stretching the nerve filaments, resulting 
 either in inhibition or stimulation of them. The BROAD LIGA- 
 MENTS are TURNED ALMOST COMPLETELY OVER, or at least very 
 badly TWISTED. This of a certainty causes circulatory changes 
 in the pelvic genitalia resulting in ovarian, tubal and uterine 
 disturbances, varying from congestion to suppuration, this de- 
 pending upon the completeness of the obstruction. 
 
 DIAGNOSIS. On vaginal examination the cervix is found 
 rather low in the vagina, its direction being a little changed. If a 
 retro version complicates the flexion, the cervix instead of point- 
 ing to the hollow of the sacrum, points forward. On examina- 
 tion of the posterior fornix, a firm body is felt in the pouch of 
 Douglas; this is the fundus or body of the uterus. To ascertian 
 whether this body is the uterus or a tumor the cervix is moved 
 at the same time. If it is the uterus it moves when the cervix 
 moves unless adhesions exist. The angle on the posterior wall 
 can be felt, .but a fibroid tumor may exist in the posterior wall, 
 and in order to differentiate the two, the bimanual examination 
 must be made in addition to the digital vaginal. 
 
 First try and see if the uterus is in normal position ; this being 
 done by pressure exerted in the anterior fornix with the internal 
 finger and just above the symphysis with the external hand. If 
 no body is found at this point, it is indicative that the uterus is 
 backward. Then place the internal finger behind the cervix, 
 well up in the posterior fornix; with pressure exerted upward, in 
 conjunction with deep pressure over the abdomen with the ex-
 
 256 DISEASES OF WOMEN. 
 
 ternal hand, the retroflexion can be felt if the abdominal wall is 
 thin and relaxed, otherwise it cannot. 
 
 If in doubt, a RECTAL EXAMINATION should be made, the 
 position of the uterus can then be palpated if there is no ascent. 
 This examination is necessary if the abdominal walls are con- 
 tracted or very thick. Having found that the uterus is flexed, 
 its MOBILITY should be tested in order to ascertain as to whether 
 or not it is held down by adhesions ; whether the fundus is caught 
 under the promontory of the sacrum; or, if it is too freely movable. 
 
 To ascertain the mobility, pressure is exerted upward on the 
 body of the uterus; it should yield readily if not fixed by adhe- 
 sions. If held down by adhesions or caught under the promon- 
 tory of the sacrum, considerable force is necessary to move it. 
 By examining the posterior surface of the uterus either through 
 the posterior fornix or the rectum, the adhesive bands can be 
 palpated. I have felt them as large as wheat straws, and very 
 tense if an attempt were made to push the uterus forward. If 
 such exist, they must be either ABSORBED or broken up before a 
 replacement can be effected. Often the uterus seems GLUED, as 
 it were, to the SACRUM OR BOWEL. In such cases, no adhesive bands 
 can be felt but the uterus seems to be securely fastened and is not 
 moved by ordinary pressure. Percussion over the sacrum, or a 
 vigorous shaking of the patient while in the knee-chest position , is 
 often sufficient to overcome such adhesions. 
 
 The sound is sometimes used to differentiate between a flexion 
 and a tumor on the posterior wall, but its use should be deferred 
 until all other methods have failed; and even then as an experi- 
 ment its use is very seldom indicated, although many physicians 
 do advise it. 
 
 Care must be taken not to mistake a FECAL IMPACTION for a 
 retroflexion. The fecal matter felt through the posterior wall of
 
 AFFECTIONS OF THE UTERUS. 257 
 
 the vagina may also be mistaken for a tumor, especially if the 
 patient has chronic constipation, in which condition the feces are 
 very hard. 
 
 A deposit in the pouch of Douglas may at first be mistaken 
 for the fundus, but locating the fundus at a different place, clears 
 up the diagnosis. Sometimes the ovary prolapses into the pouch 
 of Douglas, or an ovarian cyst may be found in this region. The 
 cyst can be diagnosed by its elasticity and softness, and the sub- 
 jective symptoms. 
 
 PROGNOSIS. The prognosis depends upon the amount of 
 inflammation ; length of standing of the case, and whether or not 
 it is a reducible flexion. If it is one of recent occurence, and 
 there is not much loss of tonicity, the prognosis is good; but if of 
 long standing and there is a metritis or atrophy, it is poor. If the 
 flexion can not be entirely overcome, relief can usually be given a 
 patient by removing the inflammation and tenderness. 
 
 TREATMENT. The treatment of retroflexion is best dis- 
 cussed under three heads; FIRST, REPLACEMENT of the organ; 
 
 SECOND, KEEPING IT IN PLACE AFTER IT HAS BEEN REPLACED; 
 
 THIRD, RELIEF OF THE SYMPTOMS where replacement is impossible. 
 The first thing to notice is the amount of inflammation and 
 whether or not the uterus can be replaced. The obstacles to re- 
 placement are fibroid tumors, adhesions and inflammatory con- 
 ditions, which make the parts too sensitive to be moved. These 
 conditions must be overcome, or at least partially reduced, before 
 the uterus can be replaced. 
 
 The treatment for fibroid tumors will be given in another 
 paragraph. 
 
 Adhesions are best treated by producing absorption of them, 
 which is done by correcting the disturbances of the circulation. 
 They are the result of an inflammatory exudate, and the inflamma- 
 
 17
 
 258 DISEASES OF WOMEN. 
 
 tion is the result of a disturbed blood supply. GENTLE FORCE can be 
 used to break them up, but care must be taken lest the inflam- 
 mation be increased or a hemorrhage result, which would bring 
 on peritonitis. If there is great tenderness in and around 
 the uterus, it can be lessened by gentle treatment around the 
 uterus; principally above it. This lifts up the intestines and 
 helps the drainage of the blood out of the uterus. Direct manip- 
 ulation, unless very light, over the point of inflammation, is not 
 indicated and sometimes makes the condition worse. 
 
 Sudden retroflexion occasionally occurs. It is due to a weak- 
 ened uterus and supports, plus some exciting cause; such as a 
 twist, strain, sudden exertion, or in fact anything causing a sudden 
 increase in the intra-abdominal pressure. It gives rise to very 
 acute symptoms and frequently produces unconsciousness. I 
 have been called to see cases in which the patient appeared to be 
 violently insane. In some of these cases the patients were at- 
 tempting to bite and scratch, or injure in any way possible, who- 
 ever came near; also pulling out their own hair by the handsfull. 
 CORRECTING the uterine DISPLACEMENT seldom failed to bring the 
 patient to consciousness, and that almost instantly. 
 
 It is very hard to explain the wide and varied effects of acute 
 retroflexion which seem to be out of all proportion to the cause, 
 yet such effects occur. The author has long since learned to 
 
 EXAMINE THE UTERUS in CaSCS of SUDDEN LOSS OF CONSCIOUSNESS, 
 
 accompanied by violent symptoms as indicated in the above 
 mentioned cases. 
 
 REPLACEMENT. There are several methods employed in 
 replacing a retro flexed uterus. The one method that I use a 
 great deal is to place the patient in the Sims, or semi-knee chest 
 position and introduce one or two fingers into the vagina, two 
 being better and are used if possible. By exerting a steady
 
 AFFECTIONS OF THE UTERUS. 
 
 259 
 
 pressure against the funclus. which is palpated through the pos- 
 terior fornix, it can be gradually straightened from its retroflexed 
 condition. 
 
 i. 79. Miiuiiiil replacement nf retroflexed uterus. 1st step. 
 
 If the uterus is quite firm and retroversion complicates the 
 retroflexion, which it usually does, pressure against the funclus, 
 coupled with traction on the cervix are usually sufficient to rotate 
 the uterus into the normal position. Traction on the cervix is 
 of little value unless the uterus Is quite firm, since it bends at the
 
 260 
 
 DISEASES OF WOMEN. 
 
 point of flexion without moving the fundus. Pressure with the 
 external hand, whereby the uterus is forced down within grasp 
 of the vaginal fingers, Is very helpful. In some cases it is advis- 
 able to balloon the vagina and then instruct the patient to cough, 
 
 FIG. 80. Manual replacement of retroflexion. 2nd step. 
 
 by which a suction force Is exerted and the uterus drawn into 
 place. 
 
 After it has been raised it can be grasped by the external 
 hand, if the abdominal wall is thin, and then having the uterus 
 between the two hands it can be readily replaced. In making 
 pressure with the external hand commence quite high, as high as 
 the promontory of the sacrum and work downward toward the
 
 AFFECTIONS OF THE UTERUS. 
 
 261 
 
 fundus. If the pressure is made low down, the tissues are made 
 more tense and the UTERUS FORCED FARTHER BACK. 
 
 FIG. 81. Manual replacement of retroflexioii. 3rd step. 
 
 If the uterus moves upward when an attempt is made to get 
 the vaginal finger behind it, resort will have to be made to a rectal 
 treatment. Through the rectum, the entire fundus can be felt;
 
 262 
 
 DISK ASKS OF WOMKX. 
 
 and by pressure exerted directly on it through the anterior rectal 
 wall, it can be bent forward far enough to be grasped by the ex- 
 ternal hand. Again the recto-vaginal method is used in some 
 
 FIG. 82. Showing manner of adjusting wire to uterus in retroflexion. 
 The cervix is fixed by finger passed through loop of wire. (First step.) 
 
 cases. This is performed by placing the index finger in the vagina 
 and the second finger in the rectum, then by steadying the cervix 
 with the index finger the fundus is pushed forward by the rectal 
 finger. I seldom Use this method.
 
 AFFECTIONS OF THE UTERUS. 263 
 
 The wire repositor invented by Dr. Still, can be used to ad- 
 
 FIG. 83. Showing manner of replacing retroflexion with wire. (Second step.) 
 
 vantage in correcting this form of displacement. The instru- 
 ment is introduced and the loop adjusted around the cervix. By
 
 264 DISEASES OF WOMEN. 
 
 lifting directly upward when the patient is in the dorsal position 
 or pulling directly forward when the patient is in the right latero- 
 prone position, the uterus will be partly forced through the loop 
 of the instrument and will be almost entirely straightened. The 
 INDEX FINGER should be introduced and the CERVIX HELD IN THE 
 LOOP if any trouble is experienced in keeping it in the loop. Then 
 by exerting pressure, as in replacement of prolapsus, the uterus 
 can be brought in position. The advantage lies in the fact that 
 the end of the loop being in the posterior fornix, pressure can be 
 made higher, that is, more directly against the fundus than can 
 be made with the unaided finger. The patient should then rest 
 
 FIG. 84. Volsella. 
 
 for awhile on her side or chest, until the uterus adjusts itself to 
 the changed relations. 
 
 The GENU-PECTORAL position is really the best one to use in 
 replacing retro-deviations not complicated by adhesions. Grav- 
 ity aids in the operation and usually very little artificial help is 
 necessary. With one or two fingers in the vagina, pressure, if 
 exerted on the posterior uterine wall, will replace it. In some 
 cases the posterior vaginal wall is retracted, thus permitting the 
 entrance of air, which forces the uterus downward; it sometimes 
 returning to the normal position. The reason for this is that when 
 a patient is in the genu-pectoral position, the weight of the in- 
 testines is taken from the pelvic viscera on account of the re- 
 traction of the intestines. This leaves a partial vacuum in the
 
 AFFECTIONS OF THE UTERUS. 265 
 
 pelvic cavity and by admitting air into the vagina the uterus 
 will be forced downward by atmospheric pressure. 
 
 If the uterus sags, that is, if the flexion is exaggerated as it 
 is in many cases, volsella are used by surgeons if replacement is 
 effected while in this position. By means of this instrument the 
 cervix can be drawn up, thus allowing the fundus to escape from 
 under the promontory of the sacrum by which the fundus is held. 
 If volsella are not used after the vagina has become ballooned, it 
 becomes necessary to use the rectal method or have the patient 
 assume the erect posture before further attempts at replacement 
 are made. If the fundus is adhered, the knee-chest positon only 
 exaggerates the flexion and on vaginal examination the cervix 
 will be found quite high, sometimes entirely out of reach of the 
 examining finger. If the fundus has been caught behind the 
 promontory of the sacrum it can be loosened by the rectal treat- 
 ment. As in all downward and backward displacements, the patient 
 should rest for awhile after the treatment, on her side or chest. 
 
 The SOUND is the last resort and is used after the above 
 methods have failed, which of course is the exception. If the 
 patient has a very thick or contracted abdominal wall, resort to 
 the sound will probably have to be made, as it is very hard to 
 manipulate the uterus if such a condition exists. After a proper 
 preparation of the sound, the patient should be placed in the Sims 
 position; with the right index finger, locate the os uteri. Then 
 with the sound in the left hand, with the concavity backward (an 
 inflexible steel sound being the best) it is pushed without rota- 
 tion directly into the uterine canal. After it has been introduced 
 the sound is rotated by carrying the handle through a wide arc 
 so as to prevent rotation of the point, which would injure the 
 mucous membrane of the uterus. The handle is then gradually 
 and gently brought backward, thus forcing the uterus into place.
 
 266 DISEASES OF WOMEN. 
 
 The replacement can certainly be effected in this way, but the 
 most careful precautions will not prevent this method of pro- 
 ceedure from producing irritation of the endometrium; hence 
 should not be used if replacement can be effected in any other 
 way. 
 
 After all, the HANDS are the BEST REPOSITORS in ordinary 
 cases. The bimanual method has several advantages over all 
 methods. First, it is safer and more convenient and not so likely 
 to be followed by endometritis ; second, the lever action of a 
 sound is avoided, whereby an undue amount of force may be used; 
 and third, the operator feels every move; the operation being 
 constantly under his control, and on noting points of resistance he 
 stops before too much force is used. 
 
 HOW TO KEEP THE UTERUS IN PLACE AFTER RE- 
 PLACEMENT. As in anteflexion, the uterine walls must be 
 strengthened; but in addition, in the case of retroflexion, the 
 ROUND LIGAMENTS must be shortened to hold the uterus in posi- 
 tion after it has been replaced. By correcting bony lesions that 
 cause a weakening of the uterine walls or their supports, and by 
 relieving the congestion, by removing the obstruction to the 
 proper return flow of blood before the attempt is made to replace 
 it; the uterus will probably be held in position after it is replaced. 
 Usually it does little or no good to replace the organ before its 
 supports have been strengthened, although in some cases it helps 
 to relieve the congestion and inflammation which exist. Fre- 
 quent local treatments to replace the uterus, as practiced by a 
 great many, ARE WRONG. They keep the parts irritated and do 
 not strengthen the supports but rather weaken them. 
 
 The patient should be instructed to not let the bladder get 
 distended or else the uterus will be forced back into its former 
 position on account of the weakness of the round ligaments.
 
 AFFECTIONS OF THE UTERUS. 267 
 
 COITION is contra-indicated before the normal tonicity has re- 
 turned to the parts. Assuming the genu-pectoral position sev- 
 eral times daily is very helpful in these kinds of cases. The pa- 
 tient should avoid the wearing of tight clothes or bands, for they 
 force the weakened uterus backward by increasing the intra- 
 abdominal pressure. Strains, lifting of weights, falls, or the 
 doing of anything which suddenly increases the intra-abdominal 
 pressure, readily displace the uterus again, and should be avoided 
 on account of the weakness of the round ligaments. 
 
 The most important is to correct the bony lesions found, 
 since they are the REAL; the PREDISPOSING causes. The uterus 
 must be nourished and strengthened; but this can not be done if 
 these lesions which shut off the blood supply are not corrected. 
 Thus they MUST BE ADJUSTED if a PERMANENT cure is expected, or 
 if the uterus is to be kept in PLACE AFTER IT is REPLACED. 
 
 PESSARIES have been recommended, but I never use them in 
 this kind of displacement, for it can be corrected a great deal 
 better without them. If an artificial support is necessary, a 
 tampon of lamb's wool should be used. A single tampon placed 
 in the posterior fornix will often hold the uterus in position. A 
 chain tampon is better in the average case, because the pressure 
 is the better distributed. 
 
 OPERATIONS have been devised whereby the uterus is fixed 
 to the abdominal wall, or the round ligaments shortened. The 
 first is performed in two way; either by an abdominal incision 
 which is called abdominal hysterorraphy ; or through the vagina, 
 this being called vaginal hysterorraphy. The operation for 
 shortening the round ligaments is called Alexander's operation. 
 Only mention will be made of these operations since operative 
 gynecology is not practiced and seldom advised by the osteopathic 
 physician.
 
 268 DISEASES OF WOMEN. 
 
 It seems that our modern gynecologists treat all forms of 
 retroflexion alike, regardless of the many different causes pro- 
 ducing them. Pessaries are introduced or operations performed, 
 
 FIG. 85. Retroversion of the uterus, let degree. 
 
 which are sometimes far more dangerous and cause more trouble 
 than the original disturbance for which the treatment was given. 
 At the conclusion, the woman is told that "the uterus is now in 
 place" and that her symptoms ought to leave. The woman, not 
 caring where the uterus is so long as she is free from pain, suffers
 
 AFFECTIONS OF THE UTERUS. 269 
 
 on, unless the cause has been removed. I know of no kind of 
 cases that so strictly belongs to the osteopathic field, since we cure 
 so many where others fail. The cause of the trouble in the indi- 
 vidual case must be found and corrected or else the routine treat- 
 ments are in vain, or at least are only palliative and serve to give 
 only temporary relief. 
 
 RETROVERSION. Retroversion is that form of displace- 
 ment of the uterus in which the fundus is turned backward and 
 the cervix forward, changing the uterine axis but not bending 
 the canal. It is frequently associated with retroflexion, and the 
 causes, in a great many cases, that produce the one will produce 
 the other. It is recognized as an early stage of prolapsus, in fact 
 it is called the first stage of prolapsus uteri; yet SLIGHT PROLAPSUS 
 is PRIMARY or else the fundus could not tip back very far on 
 account of the promontory of the sacrum. Sometimes it is 
 rotated so far backward that the fundus lies in the hollow of the 
 sacrum with the cervix pointing forward. 
 
 In this displacement, the intra-abdominal pressure is directed 
 on the fundus or anterior wall of the uterus, which exaggerates 
 the condition and promotes prolapsus. It is a form of displace- 
 ment which most frequently comes on suddenly, or, as in the 
 most chronic cases, it comes on gradually as the result of the 
 gradual relaxation. It is the forerunner of retroflexion. The 
 uterus is first retroverted, then its position weakens the support 
 of the fundus and it gradually bends backward and downward. 
 
 There are THREE accepted degrees of retroversion. In the 
 first degree, the long axis of the uterus is in line with the axis of 
 the vagina. In the second degree, the axis of the uterus occupies 
 an angle of one-hundred and thirty degrees to that of the vagina, 
 and in the third degree, an angle of ninety degrees to that of the 
 vagina; or in other words the uterus is turned as far backward
 
 270 DISEASES OF WOMEN. 
 
 as it should be forward. There are many minor degrees of re- 
 trovemon between the limits mentioned above. 
 
 CAUSES. The most frequent causes are those which put a 
 sudden strain on the round and sacro-uterine ligaments. If a 
 
 FIG. 86. Retrovereion of uterus. (Bad form.) 
 
 patient should suddenly slip, or lift a w r eight while in a stooped 
 position, it very frequently brings on an acute retro version. I 
 have seen cases that resulted from coughing or turning suddenly 
 over in bed. Sudden falls on the buttocks, such as would result
 
 AFFECTION'S OF THE UTERUS. 271 
 
 from some one pulling a chair from beneath a patient in the act 
 of sitting down, will cause it in nearly every instance. Jumping 
 from a bicycle, alighting very hard on the feet, or any jar of 
 the body, has a tendency to produce this kind of uterine displace- 
 ment. This is especially true if the bladder is distended at the 
 time of the strain or fall. I have known confirmed invalids who 
 dated their trouble back to the time when they strained them- 
 selves by carrying a bucket of water. I recently had under my 
 care a lady, who had a backward fall on the ice resulting in a retro- 
 version which has made her a chronic invalid. 
 
 These displacements the more easily occur, if any bony 
 lesion exists which has weakened the supports. If the bony 
 pelvis and lumbar spine are properly adjusted, retroversion is 
 not likely to occur; or at least it will occur with difficulty, even 
 if there is a fall or heavy strain, but when it is once thrown back- 
 ward regardless of whether or not lesions exist, the abdominal 
 pressure tends to force it still further backward and downward. 
 
 These lesions predispose to displacement by so weakening 
 the supports that the exciting cause the more readily acts. The 
 most common lesions are a subluxated innominate, sacrum, coccyx 
 and particularly lesions of the LUMBAR VERTEBRAE should be con- 
 sidered of very great importance as causative factors in retro- 
 version, as well as in any other form of uterine displacements. 
 
 A WEAKENING OF THE UTERO-SACRAL LIGAMENTS permits 
 
 the lower part of the uterus to sag down and the upper part to be 
 rotated backward. This relaxation of the utero-sacral ligaments 
 precedes nearly all cases of gradual displacement. This permits 
 the cervix to sink downward and forward, simultaneously. Un- 
 less some downward movement takes place, the average sized 
 uterus can not rotate backward to any marked extent on account 
 of the sacral promontory. This relaxation is the result of a
 
 272 DISEASES OF WOMEN. 
 
 displacement of the sacrum, to which these ligaments are at- 
 tached; lesions in the lumbar region, and intra-pelvic diseases, 
 such as subinvolution and inflammation, which affect all the 
 
 FIG. Ki. Retroversion of uterus. 2nd degree. Showing direction of 
 abdoiuinal pressure and position of intestines. 
 
 pelvic ligaments. If a distended condition of the bladder exists 
 as shown in Fig. 88 it increases tendency to backward rotation. 
 Prolapse of the bladder and rectum have a tendency to pro- 
 duce retro version. Relaxation of the perineum and vaginal
 
 AFFECTIONS OF THE UTERUS. 
 
 273 
 
 walls are found in nearly all chronic cases, probably as a cause 
 rather than an effect. The non-return of the uterus to its normal 
 form and position during the puerperium is a cause of retroversion 
 
 FIG. 88 Uterus forced back in distention of bladder. 
 
 in multipara. A knowledge of the condition of the uterus will 
 explain the occurrence of this displacement during the puer- 
 perium. In the first place the TWO FACTORS, INCREASED WEIGHT 
 and RELAXED supports are present. By permitting the patient 
 
 18
 
 274 DISEASES OF WOMEN. 
 
 to lie on the back too much, or allowing the nurse to put on a 
 tight abdominal bandage (which by the way, is an abomination) 
 the uterus is kept near, or forced backward against, the sacrum. 
 
 FIBROID TUMORS on the anterior wall of the uterus force it 
 back in retroversion as well as in retroflexion. There is marked 
 rigidity in such cases in the entire uterus plus the usual indica- 
 tions of fibroids. 
 
 SYMPTOMS. The symptoms are very similar to those of 
 retroflexion; RECTAL disturbances, deranged MENSTRUATION', 
 abnormal SECRETIONS, BEARING DOWN sensation which is worse 
 on standing or walking, PAIN over the sacrum, sometimes COCCY- 
 DYNIA and ACHING in limbs, and the REFLEX PHENOMENA. 
 The patient may have headache, hemicrania, pain in eyeballs, 
 intercostal neuralgia, gastralgia, or other visceral derangements. 
 
 The most common of the reflex phenomena are vertical and 
 occipital headache, megrim, pain between the shoulders, nausea 
 and spinal irritation. In cases in which it comes on suddenly, 
 there will be the sensation of something having "given away," 
 backache and reflex disturbances, such as nausea, and vomit- 
 ing, headache and pain in the abdomen. Instead of dysmenorrhea 
 a mild form of menorrhagia more frequently prevails. The cer- 
 vix may irritate the bladder by direct pressure and cause frequent 
 micturition, but this is the exception rather than the rule. 
 
 The pressure exerted against the rectum, increases the 
 tendency to CONSTIPATION or it interferes with the rectal circu- 
 lation, on account of which many rectal diseases result, such as 
 rectal ulcers, piles, tenesmus, prolapsus of the bo^yel and eversion 
 of the anus. 
 
 LEUCORRHEA is present on account of the congestion of the 
 uterine and vaginal walls. In recent cases, the pain is very fre- 
 quently referred to the region of the stomach, small intestines.
 
 AFFECTIONS OF THE UTERUS. 275 
 
 gall bladder, or to some organ even higher in the abdominal cav- 
 ity. There is cramping of the abdominal muscles and tender- 
 ness over the entire abdomen. 
 
 There are quite a number of conditions complicating retro- 
 version. A PROLAPSUS of a varying degree is present in most 
 cases. This is due to a change of position of uterus, its axis 
 being in a line with axis of the vagina, and to relaxation of sup- 
 ports. ADHESIONS are commonly found. The pressure of the 
 uterus on the sensitive peritoneum is very likely to irritate it and 
 set up INFLAMMATION, the result being an adhesion, unless the 
 uterus is replaced. The OVARIES AND TUBES are carried back 
 with the uterus, hence their function is impaired. There is 
 usually inflammation of the uterus and peritoneum, which 
 if present when the ovaries and tubes are in the pouch of Douglas, 
 results in adhesions. Rectal troubles as mentioned above, are 
 frequent, such as constipation, diarrhea, prolapsus of bowel, 
 tenesmus and hemorrhoids, all of which often follow from pressure 
 against the rectum. Metritis and endometritis are present in 
 most cases of backward displacement. This is due to circulatory 
 changes resulting from the displacement. 
 
 Diagnosis. The diagnosis is made by locating the CERVIX 
 LOW down in the vagina and POINTING TOWARD the OUTLET or 
 symphysis pubis. The finger passed into the posterior fornix, 
 discloses a hard, round mass, continuous with the cervix and rest- 
 ing against the rectum. By the bimanual method the fundus is 
 not found in its normal position, that is, it is not found on palpat- 
 ing through the anterior fornix. 
 
 By the RECTAL examination the fundus and body are plainly 
 felt resting against the rectum. The uterus is usually found to 
 be rigid and fixed in its position. I have seen a great many cases 
 in which the uterus entirelv occluded the lumen of the bowel and
 
 276 DISEASES OF WOMEN. 
 
 had to be forced forward before the finger could be introduced 
 into the rectum. A fibroid tumor on the posterior uterine wall 
 may cause rectal symptoms, but the direction of the uterine axis 
 as demonstrated by the position of the cervix and fundus, depth 
 
 FIG. 89. Manual replacement of retroverted uterus with patient on left side. (1st step.) 
 
 of uterine cavity, and the conjoined examination, will clear up 
 the diagnosis. 
 
 TREATMENT. In cases in which there is retention of tone 
 in the pelvic floor, vaginal and abdominal walls, and the uterus 
 with its ligaments, and in cases in which the displacement came 
 on suddenly, the treatment consists of replacement. Such cases 
 are found principally in nullipara .
 
 AFFECTIONS OF THE UTERUS. 
 
 277 
 
 In cases in which all the supports are relaxed and weak, 
 and the displacement is the result of causes more or less continu- 
 ous for quite a long while, the primary treatment is one directed 
 to RESTORE TONE to the support AFTER WHICH, replacement of 
 
 FIG. 90. Manual replacement of retroverted uterus. (2nd step.) 
 
 the uterus. Yet in such cases it is well to replace the organ from 
 time to time, as this helps to relieve the congestion, lessens its 
 weight, hence assists in restoring strength to the pelvic floor. 
 Replacement is effected in the ways similar to those mentioned 
 under the head of replacement of retroflexion. 
 
 Pressure exerted against the posterior uterine wall by means 
 of the index finger, either through the posterior fornix or anterior 
 rectal wall, is a method I most commonly use at first to determine
 
 DISEASES OF WOMEN. 
 
 the extent of adhesions and size of the uterus. If it cannot be 
 replaced in this way I place the patient in the semi-knee chest 
 position and introduce two fingers in the vagina. Pressure is 
 
 FIG. 91. Manual replacement of retroverted uterus completed. The cervix is forced 
 as high as possible and the intestines pushed behind uterus thus preventing 
 
 recurrence.
 
 AFFECTIONS OF THE UTERUS. 
 
 279 
 
 exerted against the posterior uterine wall, through the posterior 
 fornix by the middle finger. Traction backward on the cervix 
 with index finger tends to pry the uterus forward. Combining 
 the two, that is, pressure forward on the body and traction back- 
 
 FIG. 92. Replacing retroverted uterus with wire, finger in vagina. 1st step. 
 Patient on right side. 
 
 ward on cervix, the uterus is rotated around the fixed point, the 
 attachment of the utero-sacral ligaments. 
 
 If adhesions are present they can be gradually broken up by
 
 280 
 
 DISEASES OF WOMEN. 
 
 this method. In some cases in which the fundus seems glued to 
 the sacrum it is hard to get pressure high up that is sufficient to 
 push the fundus forward. In such cases the "Old Doctor's" 
 
 FIG. 93. Replacing retroversion with wire repositor. 2nd step. 
 
 wire is a handy substitute; with it pressure can be exerted high 
 up against the body in the posterior fornix, and the uterus forced 
 forward. 
 
 Sometimes simply admitting air into the vaginal cavity will 
 cause the uterus to resume its normal position, unless there are 
 adhesions, or unless it is caught behind the promontory of the 
 sacrum. If these methods fail, and they seldom do, a sound is 
 commonly used; the replacement being accomplished by this 
 method. To keep the uterus in place let the patient rest either 
 on her face or side as long as possible after the treatment and avoid 
 the conditions that were primarily responsible for the displace- 
 ment.
 
 AFFECTIONS OF THE UTERUS. 
 
 281 
 
 The obstacles preventing, or making replacement difficult, 
 are INFLAMMATION OF the uterus and ADNEXA, and adhesions or 
 incarceration of the fundus under the promontory of the sacrum. 
 Adhesions can gradually be overcome by repeated attempts at 
 
 FIG. 94. Replacement of retroverted uterus with wire repositor completed. Pa- 
 tient on right side. Note position of handle. 
 
 replacement whereby the bands are stretched or broken. In 
 cases of pelvic inflammation, the tenderness should at least be 
 partly relieved before much local treatment is given, unless dis- 
 placement is the only cause of it. To relieve the tenderness,
 
 282 
 
 DISEASES OF WOMEN. 
 
 treatments given in the genu-pectoral position by which the pro- 
 lapsed condition of the pelvic and abdominal viscera are at least 
 partly overcome, are the best. In chronic cases, strengthen the 
 supports, particularly the round and sacro-uterine ligaments by 
 osteopathic treatment. This treatment is directed to the re- 
 duction of lesions both bony and muscular. 
 
 FIG. 95. Showing uterus forced through the loop of the repositor in replacing re- 
 troversion and prolapsus. 
 
 . According to most writers all the uterine ligaments contain 
 muscle fibers, especially the round and sacro-uterine. By re- 
 storing tone to these ligaments the uterus will gradually be drawn 
 into place. Advise the patient against walking or standing too 
 much, or doing any work whereby strain will be thrown on the 
 abdomen, until after the uterine supports have been strengthened.
 
 AFFECTIONS OF THE UTERUS. 283 
 
 LATERO-FLEXION. The uterus usually lies somewhat to 
 the left of the median line of the body. Sometimes by inflam- 
 mation of one of the broad ligaments, cicatricial tissue will be 
 formed, this contracting and drawing the fundus or body to 
 that side. This constitutes latero-flexion. It can readily be 
 DIAGNOSED by locating the fundus and cervix by the bimanual 
 method, the fundus being found bent to one side or the other. 
 On vaginal examination the broad ligaments on the affected side 
 will be found tender and tense and the fundus can be felt drawn 
 to that side. 
 
 LATERO-VERSION is a condition similar to latero-flexion, 
 but in addition, the cervix is drawn to the opposite side to that 
 to which the fundus is drawn, and the uterus lies at an angle. 
 It is, like latero-flexion, also caused by adhesions or by growths 
 that are sometimes found between the layers of the broad liga- 
 ments. No SPECIAL SYMPTOMS, except sterility, follow these 
 lateral displacements; however, there may be cellulitis or inflam- 
 mation of the broad ligaments on the affected side, such being 
 indicated by tenderness and contracture of the tissues. Latero- 
 versions can be readily recognized by bimanual palpation. They 
 are treated by producing absorption of the inflammatory exu- 
 dates and restoring a normal circulation to and through the broad 
 ligaments. This is accomplished best by correcting lesions of 
 the innominate on the same side, and by local treatments directed 
 to restore normal position and mobility to the uterus. 
 
 There are various UTERINE DISPLACEMENTS that are not 
 typical; that is, there is a combination of two or more displace- 
 ments. Often a case is found in which the UTERUS HAS SLIPPED 
 BACKWARD, the uterine axis is unchanged, but the cervix is com- 
 pressing the rectum. Again the uterus may be retro verted against 
 the sacrum, yet there is a curve in the uterus making it a slight
 
 284 DISEASES OF WOMEN. 
 
 anteflexion. In such cases the uterus seems to be moulded to 
 the anterior surface of the sacrum. 
 
 ASCENT OF THE UTERUS occurs in some forms of disease of 
 neighboring organs or structures. In PERITONITIS or bowel dis- 
 turbances or diseases of the peritoneum, the uterus is drawn 
 upward. In fleshy people the uterus is often very high. In 
 arthritis deformans, the uterus is often drawn upward. In a 
 case treated by the author the uterus could scarcely be reached 
 by vaginal examination. Fibroid tumors when large, draw the 
 uterus upward. 
 
 Torsion of the uterus is usually not an independent displace- 
 ment but one complicating the more common uterine deviations. 
 This displacement is the result of the thickening of the connective 
 tissue surrounding the supra-vaginal portion of the uterus. This 
 thickening follows parametritis on account of the inflammatory 
 deposit in the connective tissue. 
 
 The effect is similar to that in lateral deviations, that is a 
 sense of pulling or drawing in the affected side, accompanied by 
 "side ache," and pain, which are frequently diagnosed as OVARIAN 
 TROUBLE. The TREATMENT is the same as in lateral deviations. 
 
 COMPLICATIONS OF UTERINE DISPLACEMENTS. Nearly 
 all forms of displacement set up an inflammation either in or 
 around the uterine walls. Metritis, cellulitis, peritonitis, oophor- 
 itis and salpingitis are the most frequent complications. In 
 other cases these inflammatory conditions, mentioned above, 
 may be primary and the displacement follows from contraction 
 of the ligaments ; or perhaps the ligaments may be left in an atonic 
 condition and the uterus not being securely supported becomes 
 displaced. The MORE ACUTE the DISPLACEMENT, that is, dis- 
 placements resulting from falls or like causes, the MORE INTENSE 
 and acute the complications. The -MORE GRADUALLY the dis- 
 placement occurs, the less intense the complications.
 
 AFFECTIONS OF THE UTERUS. 285 
 
 In acute displacements, the complications are due to the 
 congestion and inflammation in and around the uterus. In 
 gradual displacements the complications result mostly from pres- 
 sure or traction of the uterus on the adnexa. The complica- 
 tions can seldom be cured, without correcting the original disturb- 
 ance BUT ARE OFTEN RELIEVED. 
 
 The MENSTRUAL DISORDERS depend upon the amount of 
 blood in the uterus, the amount of inflammation, the degree of 
 contraction or relaxation of the uterine walls, the size of the in- 
 ternal and the external ora, and character of the expellant forces 
 of the uterus ; any or all of which may be affected by the displace- 
 ment. 
 
 The weakest abdominal or thoracic viscus will be affected 
 reflexly, producing a functional disturbance in that organ. 
 
 The following named affections constitute a partial list of 
 the complications of uterine displacements: 
 
 Eye troubles, pain in the ear, toothache, migraine, throat 
 disturbances, enlarged thyroid glands, hypertrophied tonsils; 
 mammary disturbances, such as a retracted nipple, lumps in the 
 breast, atrophy, mastitis and ulceration resembling cancer; pal- 
 pitation of the heart; stomach disorders, mainly dyspepsia and 
 nausea, liver engorgements, liver spots; cutaneous eruptions, 
 intestinal indigestion, enteralgia, kidney affection; spinal curva- 
 ture and irritation, sciatica, Mortons toe, or cramping of toe, 
 and pain at knee, foot or heel. 
 
 REMEMBER that it does very little good to replace the dis- 
 placed uterus when the supports are soft and weak, on which 
 account one should first direct the treatment to BUILD up and 
 STRENGTHEN the SUPPORTS; that a VERSION is usually of SUDDEN 
 OCCURRENCE, while a FLEXION is a GRADUAL one; that temporary 
 relief can often be given by SIMPLY LIFTING UP THE UTERUS; that
 
 286 DISEASES OF WOMEN. 
 
 in case of syncope, the patient can frequently be aroused by local 
 treatment when all other methods have failed; that a chronic 
 pain below the waist line, or headache in the top of the head, 
 points to uterine disturbances; that 90 per cent, of women, have 
 some form of uterine displacement which Is the cause of most of 
 their pains and aches. Also remember that a fixed, immovable, 
 or slightly movable uterus is abnormal regardless of its position ; 
 that a uterus that is very hard or quite soft is abnormal. Dr. Still 
 says that a uterus is abnormal if it has dropped through, or is 
 putting traction on, the various bands or ligaments that cross 
 the pelvic cavity surrounding the uterus, bladder and rectum. 
 These bands of which the broad ligaments form the greatest part, 
 constitute the "pelvic " floor. By lifting the uterus through the 
 opening resulting from a separation of these ligaments and fascia, 
 by means of the wire uterine repositor, the symptoms of the dis- 
 placement can be relieved. In many cases of female trouble 
 with the usual symptoms of displacement in which the uterus is 
 apparently normal, simply lifting up the uterus will usually re- 
 lieve the pain and ache. 
 
 INVERSION OF THE UTERUS. Inversion of the uterus is 
 a partial or complete turning of the organ inside out ; so that the 
 endometrium, if inversion is complete, forms the covering mem- 
 brane, and the peritoneum the lining of the uterine cavity. A 
 partial inversion is one in which some part of the uterine wall, 
 usually the fundus, is depressed in a way similar to a dent in a 
 hat. In complete inversion the uterus is completely turned 
 wrong side out. This condition is usually associated with child- 
 birth as a cause, but some times it results from other conditions, 
 such as senile atrophy of the uterus, or softening of the walls from 
 other causes. 
 
 Causes. In order that inversion be produce'd, there must
 
 AFFECTIONS OF THE UTERUS. 287 
 
 be a DILATATION OF THE UTERINE CAVITY; a WEAKNESS of a part 
 
 or all of the WALL of the uterus, and SOME FORCE must be exerted, 
 such as the abdominal pressure or traction from below as in. an 
 adhered placenta or polypus that is attached to the mucous 
 membrane lining the upper part of the uterine cavity. 
 
 The dilated or DISTENDED cavity, is most frequently found 
 immediately after parturition, and being one of the most essential 
 causes . we find inversion most frequently occuring at this time. In 
 order for the cavity to exist or be formed; there must be a thin 
 and weakened condition of the walls of the uterus. This weak- 
 ness follows an over-distention of the uterine cavity. This re- 
 sults from HYDROPS amnii or from TWIN PREGNANCY, or is caused 
 by some interference with the nutrition of the walls. If there is 
 traction from below, such as pulling on the UMBILICAL cord during 
 the THIRD STAGE OF LABOR, or if the pressure of a polypus occurs 
 while the walls are in this weakened condition, a partial inver- 
 sion will result. If there are violent contractions during the 
 third stage of labor, it may, like invagination of the intestines, 
 force the fundus down into the uterine cavity. This may occur 
 in the latter part of the second stage of labor, that "is, immediately 
 following the expulsion of the child. 
 
 Frequently it is caused by the improper management of the 
 third stage of labor. INJUDICIOUS KNEADING of a weakened, 
 flabby uterus during the third stage of labor, especially if local- 
 ized, that is confined to one part of the uterus, will often cause an 
 indentation from unequal contraction. 
 
 A SHORT cord is sometimes the cause of inversion. A weak 7 
 ened condition of the uterine wall at the placental site, permits of 
 a partial inversion at that point. 
 
 Inversion not associated with parturition, is sometimes the 
 result of a fibroid tumor forcing in a weakened wall. A polypus
 
 288 
 
 DISEASES OF WOMEN. 
 
 attached to the lining of the fundus may, by setting up uterine con- 
 tractions, be forced downward and will pull the uterus with it. 
 In cases of senile atrophy or where there is a circumscribed metri- 
 tis, that part of the uterus may partially invert. I have seen 
 cases in which there were a great many disturbances at or follow- 
 ing the menopause, which were due to a partial inversion. 
 
 FIG. 96. Inversion of the uterus showing different degrees. (Diagrammatic.) 
 
 The ESSENTIAL ELEMENT, which is the predisposing cause in 
 inversion, is an ATONIC STATE OF A PART OF THE UTERINE WALLS, 
 favoring relaxation of the muscle fibers. This leads to a partial 
 prolapse of a portion of the wall and is associated with a regular 
 contraction of the muscular tissue. The prolapsed portion is 
 treated by the uterus as a foreign body; it excites uterine con- 
 traction, which ends in a complete or partial expulsion, of the 
 prolapsed part. The cause of this atonic state of portion of the
 
 AFFECTIONS OF THE UTERUS. 289 
 
 uterine wall in chronic cases can be, in most instances, traced 
 back to a lesion in the bony frame work, which interferes with the 
 nutrition of the uterine walls. 
 
 SYMPTOMS. In complete inversion, a tumor is seen pro- 
 truding from the vagina, simulating a polypus. There is hem- 
 orrhage, constant or periodical, bearing down pains which in- 
 crease on movement of the body and vesical and rectal disturb- 
 ances. These symptoms vary with the degree of inversion and 
 the cause of the trouble. If it is a complete inversion folio whig 
 delivery, all these symptoms are exaggerated and the hemorrhage 
 may be fatal, but if it is a chronic case the reflex pains are the 
 principal symptoms. In acute forms, the patient in many cases, 
 collapses from loss of blood. 
 
 If the PARTIAL INVERSION is the result of parturition, the 
 LOCHIAL DISCHARGE will continue for several days, or even weeks 
 longer, than the normal. The flow r will be abnormal in character 
 and quantity, it usually becoming arterial. AFTER-PAINS are 
 present in a severe form. This condition exists in some cases for 
 quite awhile after delivery and occasionally causes a marked 
 derangement of the nervous system. Dr. C. E. Still recently re- 
 ported to me a case of PUERPERAL insanity treated by him, that 
 occurred within a few weeks after labor. The usual symptoms 
 were present, that is, the lochial discharge was abnormal and the 
 after-pains severe. On local examination a partial inversion 
 was discovered. A large blunt sound was introduced into the 
 uterus by which the fold was straightened by turning the sound 
 while IN UTERO. The patient was immediately relieved and in a 
 short time, (only two treatments were given) she became per- 
 fectly rational and was soon discharged as cured. The patient 
 remained well when last heard from, some months afterwards. 
 
 In CHRONIC cases there is an anemic condition and reflex 
 
 19
 
 290 DISEASES OF WO.MEX. 
 
 circulatory disturbances such as TINNITUS AURIUM and chronic 
 headaches. Menstrual irregularities occur in chronic cases. The 
 flow is profuse at some periods, premature in others, and fre- 
 quently there is marked cramping. The menstrual period will 
 often last a week or more, which results in nervousness and weak- 
 ness. 
 
 DIAGNOSIS. INVERSION FOLLOWING DELIVERY should be 
 suspected from the severe pain, the hemorrhage more or less con- 
 tinuous, and the absence of the fundus of the uterus upon the 
 placing of the' hand upon the lower part of the abdomen. The 
 diagnosis is made by seeing the uterus as a raw looking tumor 
 lying between the labia, with the large end the more prominent. 
 
 Apart from obstetrical cases it is usually very difficult to 
 diagnose a slight inversion. In the ordinary type a fold can 
 sometimes be felt through the fornix in the uterine wall.' It 
 feels as if the uterus had settled or folded down on itself as would 
 an empty sack if unsupported. In such cases if a large sound, 
 one as large as the index finger, is introduced and the fundus 
 lifted or the sound rotated as above suggested, this fold can be 
 straightened but possibly will not remain normal but recur, since 
 the weakened uterine wall is the primary cause. 
 
 In recent cases, prolapsus is diagnosed from complete in- 
 version by locating the cervix and os at the lower end of the pro- 
 truding mass. In procidentia the tumor is narrow at the base 
 and wide at the upper part, while in inversion it is just the re- 
 verse. The covering of the protruding tumor will assist in the 
 diagnosis, since in prolapsus it is smooth and shiny; in inversion 
 it is a mucous membrane and is raw and bleeding. 
 
 A POLYPUS may protrude and thus simulate an inversion. 
 The color, consistency and mode of onset help, but a complete 
 diagnosis is made by a rectal and bimanual examination, this 
 revealing the uterus to be in the pelvic cavity.
 
 AFFECTIONS OF THE UTERUS. 291 
 
 TREATMENT. The TREATMENT differs in the two forms of inver- 
 sion . When it immediately follows childbirth all that is necessary is 
 to replace the organ, it being comparatively easy in such cases. 
 Pressure exerted directly against the fundus will usually accom- 
 plish the re-inversion. Sometimes one finger is placed in the 
 rectum in order to assist in the operation , since in this manner the 
 cervix can be reached and the os be helped to dilate. In irre- 
 ducible cases an operation is resorted to by which the os is arti- 
 ficially enlarged or a part of the fundus amputated. 
 
 Following reduction the uterus should be made to contract 
 in order to prevent too much hemorrhage. This is done by work 
 directly over the uterus through the abdominal wall, or if it can 
 not be accomplished this way, an astringent solution is injected 
 directly into the uterine cavity. 
 
 In chronic cases not immediately following parturition, a 
 dull blunt sound as mentioned above, can be introduced into the 
 uterus to push up the partial inversion. Care should be exer- 
 cised in this or else the weakened uterine wall will be injured, 
 and also as large a sound as can be introduced should be used, 
 since it lessens the liability to injury. 
 
 Since these changes are due to atrophy and weakening of 
 the uterine wall the treatment should be directed to strengthen 
 them in addition to replacing the prolapsed condition of the wall. 
 When the inversion is produced by pressure from a growth such 
 as a fibroid tumor, the treatment should be directed to reduce 
 the growth or the pressure exerted by it, since that is the cause of 
 the trouble. In cases of partial inversion that occur in multi- 
 para after they have passed the menopause, little can be done on 
 account of the atrophied and weakened condition of the uterine 
 wall. Strong stimulating treatment applied to the back, to cor- 
 rect the muscular as well as the bony lesions, is beneficial, and if 
 the case is not one of too long standing, or one in which the walls 
 have not become very much weakened, the condition can be 
 helped if not cured.
 
 292 DISEASES OF WOMEN. 
 
 TUMORS OF THE UTERUS. 
 
 DEFINITION AND CLASSIFICATION. Gould defines a 
 tumor as (1) "any enlargement or swelling of a part;" (2)"a 
 new growth not the result of inflammation or hyperplasia. " 
 The true tumors are usually included under the latter definition. 
 In structure, a tumor consists of tissues which resemble the normal 
 tissues of the body either in a mature or an immature state. 
 Thus a tumor may be composed of muscle fibers, connective 
 tissues, fat, etc., or of cells like those constituting the epithelium. 
 They are HOMOLOGOUS when they resemble or continue to grow 
 in the tissue in which they originate, merely displacing the sur- 
 rounding tissue. Such are usually innocent tumors. The HETER- 
 OLOGOUS tumors originate in one tissue, and retaining the type 
 of that tissue, INVADE ANOTHER tissue. They are generally 
 malignant, the epithelioma being a type. Innocent tumors are 
 usually composed of a matured tissue of the body, while the 
 malignant on the other hand usually consists of cells like those of 
 the lower organized or immature tissues. 
 
 FIBROID TUMORS of the uterus are innocent tumors which 
 occur in or on any part of the uterus, but are found most fre- 
 quently to be located in or on the fundus. In structure, they 
 are made up of the constituents of the uterine wall, that is, con- 
 nective tissue, unstriped muscle fibers, and fibrous tissue, and 
 should properly be called fibro-myomata. They also contain 
 blood vessels, lymphatics, occasionally glandular structures and 
 possibly nerves.
 
 TUMORS OF THE UTERUS. 293 
 
 The tumors that are composed almost entirely of muscular 
 fibers are rare. Occasionally in the early stages, that is before 
 the tumor becomes an inch in diameter, these fibers predominate 
 but soon are displaced by connective or fibroid tissue. The 
 INTERSTITIAL variety is always at first composed of muscle 
 fibers, hence are called myomata. As the tumor develops the 
 muscle fibers are gradually replaced by fibrous tissue, so when the 
 tumor becomes as large as a croquet ball, it is almost entirely 
 fibrous in character. Fibro-myomata are the most frequent of 
 uterine growths and occur most commonly between the ages of 
 thirty and forty-five. 
 
 Hirst, in speaking of fibre-myoma, says that it may be found 
 in the uterus of at least 20 per cent, of women over thirty-five 
 years of age. This is possibly too high an estimate for all cases, 
 but probably not too high for nullipara. Their growth is very 
 slow, the rapidity depending upon the vessel union with the 
 uterus. 
 
 FIBROMATA, as a rule, increase in size ONLY DURING THE 
 period of sexual activity and remain stationary or undergo atrophy 
 after the menopause. They seldom if ever originate in the uterus 
 before puberty or after the menopause. A case of a fibroid tumor 
 in a lady 63 years old came under my care. The tumor was 
 about three inches in diameter, very hard, but caused little in- 
 convenience outside of some pressure disturbances. The uterus 
 was forced down almost to the degree of procidentia. Although 
 such displacements are, as a rule, quite painful, yet it caused this 
 patient but little trouble. 
 
 I have seen in the young, localized enlargements in the lower 
 part of the abdomen which had been diagnosed as fibroid tumors, 
 but they turned out to be some form of bowel trouble, such as 
 impaction, pregnancy, congestive hypertrophy of the uterus, 
 ovarian cyst, or ascites.
 
 294 DISEASES OF WOMEN. 
 
 Fibroid tumors are RARELY FOUND SINGLY in the uterus, 
 there usually being several, which are irregular, and vary in size. 
 As high as fifty different tumors have been found. In such cases 
 they coalesce and form one irregular conglomerate tumor, hard 
 and nodular to the touch. 
 
 Their SIZE varies from that of a pea, to that of a tumor 
 weighing fifty or sixty pounds, or even as high as one hundred 
 and forty five pounds, as reported by one author. They are most 
 frequently located in the posterior wall of the fundus; less fre- 
 quently in the anterior wall and sides. It is a common saying 
 that a woman is ALWAYS LOOKING FOR A TUMOR, and I have seen 
 them apparently disappointed when told that they did not have 
 one. 
 
 STRUCTURE. FIBRO-MYOMATA are composed of the same 
 elements as the uterine wall, namely, muscle fiber, connective 
 tissue and fibroid tissue. The proportion varies, but in most 
 cases the fibrous tissue predominates. The tumor feels hard to 
 the touch and has a glistening appearance on section. It is sur- 
 rounded by a covering or capsule, thus admitting of the opera- 
 ation called ENUCLEATION. The number of blood vessels pene- 
 trating its substance depends upon the amount of fibrous tissue 
 present, since the greater amount of fibrous tissue present the 
 fewer vessels and the less marked the menstrual disturbances. 
 
 If the muscle fibers predominate, the tumor becomes vascu- 
 lar and grows rapidly. The structures immediately around the 
 tumor are very vascular, and sometimes the engorged vessels can 
 be felt through the abdominal wall. NERVES have been traced 
 into the substance of the tumor, but there seems to be no sensa- 
 tion in the tumors except where they are covered with a mucous 
 membrane. 
 
 VARIETIES. THREE VARIETIES of fibroid tumors have been
 
 TUMORS OF THE UTERUS. 
 
 295 
 
 recognized SUBMUCOUS or polypoid, INTERSTITIAL or INTRA- 
 MURAL, and SUBPERITONEAL. At first they are intramural, that is, 
 located in the uterine wall, but as they develop they usually ap- 
 
 9H 
 
 FIG. 97. Submucous fibroid tumor of uterus. 
 
 proach one of the two free surfaces, thus producing the other two 
 forms. 
 
 Submucous fibroids are the most important clinically. On 
 account of their position, nature regards them as foreign bodies 
 and tries to expel them, especially during menstruation by uterine
 
 296 
 
 DISEASES OF WOMEN. 
 
 contraction. This simulates labor and causes the most excruciat- 
 ing pain, especially if the tumor becomes pedunculated. They 
 lie usually beneath the mucous membrane, and as they are en- 
 larged, project into the uterine cavity. When they hang free 
 they are called fibrous polypi. The uterine contractions ex- 
 cited by their presence, leads in some cases, to pedunculation of 
 
 FIG. 98. Intramural fibroid tumor of uterus. 
 (1) Uterine cavity. (2) Vagina. (3) Urethra. (4) Symphysis. (5) Bladder. 
 
 the tumor or even its expulsion from the uterine cavity. I have 
 record o numerous cases in which the osteopathic treatment, by 
 exciting uterine contraction, produced expulsion of the tumors 
 belonging to this class. Again the hemorrhage is most marked 
 in this kind of fibroid tumor on account of the congestion of the 
 mucous membrane. 
 
 The intramural or interstitial form remains in the substance
 
 TUMORS OF THE UTERUS. 
 
 297 
 
 of the uterine wall and does not become peclunculated. This 
 is the form in which the greatest number is found. 
 
 The subperitoneal form grows outward and upward into the 
 peritoneal cavity. It usually has a pedicle and upon the length 
 
 FIG. 99 Superltonenl form of fibroid tumor on posterior wall. 
 
 of the pedicle depends the mobility of the tumor. It may ascend 
 and carry the uterus with it, thus producing elongation of the 
 uterine cavity, or it may have a long pedicle , thus allowing it to 
 fall down from the abdominal into the pelvic cavity, and produce
 
 298 
 
 DISEASES OF WOMEN. 
 
 pressure symptoms. Sometimes the pedicle becomes TWISTED,. 
 this producing a disturbance of the circulation to the tumor. If 
 this occurs gradually, nutrition will be shut off and cessation of 
 growth follow, but if it occurs suddenly, gangrene of the tumor 
 may set in and result in a fatal peritonitis. This form can be dis- 
 tinctly felt and clearly outlined through the abdominal wall, 
 after it has reached the size of an apple. 
 
 CAUSES. The cause of FIBROID tumors depends upon dis- 
 turbed circulation which results in a deposit of material by the 
 blood, from which new formations are produced. They are devel- 
 oped during the fruitful age of the woman. From this we would 
 reason that their formation is related in some way to the DEVEL- 
 OPMENT and ACTIVITY of the SEXUAL APPARATUS. They are 
 most COMMONLY FOUND IN THE STERILE, whether as a cause or re- 
 sult I do not know. COITUS, MASTURBATION, and UNGRATIFIED 
 SEXUAL desire are INDUCIVE to uterine and ovarian congestion. 
 It has been asserted that if the uterine muscle fibers are denied 
 the opportunity of PHYSIOLOGICAL HYPERTROPHY, which comes 
 with pregnancy, they are prone to become pathologically en- 
 larged from new formations in the musculo-fibrous tissue in con- 
 sequence of the various sitmuli mentioned above. 
 
 The REPEATED CONGESTION of the uterus coincident with 
 menstruation without any period of rest, is a very probable cause. 
 Each organ must have its period of rest, and if this engorgement 
 of the uterus is not relieved by a physiological process, such as 
 pregnancy, it will predispose to deposits and new formations. 
 The function of the uterus is to provide a place for gestation and 
 to furnish nourishment for the embryo from conception to end of 
 term, and if this function is interfered with, disease especially of 
 a tumorous nature is very likely to result. Sexual activity and 
 irritation accompanied by the use of means to prevent conception,
 
 TUMORS OF THE UTERUS. 299 
 
 are certainly important causes. It has been noted by the author 
 and others that in TYPICAL CASES OF FIBROID tumors there was an 
 
 INTENSE DESIRE UPON THE PART OF THE WOMAN FOR CHILDREN. 
 
 This is true of the unmarried nullipara, as well as the married. 
 This condition leads to repeated pelvic engorgements which are 
 necessary in the production of tumors. 
 
 In looking over the record of cases that I have treated, I find 
 that in most cases there was a subluxated innominate, or a rigid 
 spinal column in the lumbar region, or both of these conditions 
 were present. If the symphysis is carefully examined, tender- 
 ness and irregularities will be discovered, which are indicative of 
 an innominate lesion. THE VASO-MOTOR CENTERS controlling 
 the uterine circulation are in the LUMBAR SPINAL CORD and a rigid 
 spine, or a posterior curvature occuring in this region, will affect 
 these centers. This keeps up a constant irritation of the uterus, 
 which, like the bruise of the bark of a cherry tree, terminates 
 in an exudate or deposit. The blood supply is deranged. Blood 
 that is formed for another part of the body is possibly switched 
 off and its contents deposited in the vascular uterus. Each part 
 of the body has blood formed especially for it, and it seems reason- 
 able to me that if blood carrying food that was not intended for 
 the uterus, should get into the uterus, its load would be deposited 
 after repeated attempts to escape, regardless of the so-called 
 SELECTIVE FUNCTION which each tissue is supposed to have. If 
 the patient first has these bony lesions, then the causes above 
 mentioned may the more readily act. If the first of the above 
 mentioned causes were true, why does not every sterile woman 
 between the age of thirty and forty-five, have a fibroid tumor? 
 
 I know FROM EXPERIENCE that THESE LESIONS ARE THE MOST 
 
 IMPORTANT AS CAUSATIVE FACTORS, because I have cured cases 
 by correcting these lesions.
 
 300 DISEASES OF WOMEN. 
 
 Another explanation lies in the fact as stated above, that the 
 CENTERS for the TONE and NUTRITION OF THE UTERINE MUSCLE 
 
 FIBERS ARE IN THE ANTERIOR HORNS OF THE GREY MATTER OF THE 
 
 LUMBAR SPINAL CORD. If the cells in these horns are made to 
 act abnormally there will be an effect in the parts supplied. A 
 
 RIGID LUMBAR SPINE Will affect the ACTIVITY of the CELLS by IN 
 
 TERFERING WITH THEIR NUTRITION. Myoma, reasoning from 
 the above, would be the primary tumor formed. The rigidity of 
 the lumbar spine results FROM OCCUPATION wherein the patient 
 is on her feet a great deal. 
 
 The discs flatten and lose their elasticity. The VERTEBRAE 
 are thereby approximated, which condition necessarily LESSENS 
 the size of the inter vertebral foramina. The STRUCTURES passing 
 through these foramina would then be affected in some way. 
 
 A displaced uterus is frequently a forerunner of fibroid tumors. 
 The formation of some of these tumors can be traced back to a 
 fall or heavy lift, but this has particular reference to those of 
 quick formation. 
 
 I sometimes compare their formation to an excresence on an 
 oak or an exudate on a cherry or peach tree. There must have 
 existed some disturbance to the supply of nutrition to that part 
 from some sort of injury. The circulation of the sap must have 
 been disturbed in some way. So it is with a foreign growth on 
 the uterus. It is a result of a disturbance to the circulation, an 
 irritation somewhere, and this disturbance is in most cases the 
 result of a BONY LESION in the above mentioned places, a uterine 
 displacement or an injury to it from the improper use of a sound 
 or other instrument. 
 
 GENERAL WEAKNESS, which implies local weakness, has been 
 mentioned as a possible cause of fibroids. This, physicians have 
 attempted to overcome by the administration of a diet composed 
 largely of meats.
 
 TUMORS OF THE UTERUS. 301 
 
 The "Old Doctor" has often remarked that it was very un- 
 usual for a FOUR FOOTED ANIMAL to have a fibroid tumor. After 
 examining a great number of animals and not finding any indica- 
 tions of fibroids, he came to the conclusion that tumors were part- 
 ly due to the POSITION OF THE ANIMAL. This position prevented 
 enteroptosis or a packing of the pelvic cavity with intestines .In 
 women, the UPRIGHT POSITION tends to produce enteroptosis. This 
 is counteracted in part by the mesentery and the abdominal wall. 
 The abdominal walls are weakened by the character of the dress, 
 that is, its function is subserved by the tight dress, and when the 
 function of a muscle is suspended, it atrophies. Thus it is in 
 the case of the abdominal muscles, atrophy follows and then 
 comes enteroptosis. This results in a PACKED and CONGESTED 
 pelvis. A deposit must follow and finally a tumor forms. I BE- 
 LIEVE THAT EXTEROPTOSIS EXISTS IN NINETY PER CENT. OF ALL 
 
 CASES OF FIBROID TUMORS. Incidentally the remark might be 
 made, that if the patient would walk on all fours for a period of 
 time a cure, unless the disease had progressed too far, would fol- 
 low. 
 
 SYMPTOMS. FIBROID TUMORS, like other pathological 
 growths of the uterus, usually produce no symptoms until they 
 are quite well developed. A great many people do not know 
 that they have a tumor until told so by their physician, since if 
 the tumor is small, there are very few noticeable symptoms. The 
 most important is that of hemorrhage. This comes on gradual- 
 ly, instead of suddenly as in cancer of the uterus, at first, as an 
 increase of the menstrual flow, which .is called MENORRAGHIA. 
 After a time this may amount to a flooding or there may be irregu- 
 lar hemorrhages or METRORRHAGIA. The SIZE of the tumor, un- 
 less it is too fibrous, increases just immediately before and during 
 menstruation. The amount of increase in size is quite indicative
 
 302 DISEASES OF WOMEN. 
 
 of the degree of menorrhagia. This hemorrhage does not come 
 from the tumor, but from the thickened mucous membrane lining 
 the uterine cavity. In some cases the loss of blood threatens the 
 patient's life. The writer saw a case recently in which there had 
 been flooding for over a week. The patient was ANEMIC, ears and 
 lips colorless, pulse rapid and weak and there was a condition of 
 almost complete syncope. 
 
 The HEMORRHAGE is not so marked in the subperitoneal form 
 as in the other types of fibroid tumors, but there is usually some 
 increase in amount of menstrual discharge. In the MUCOUS 
 form, the hemorrhage is GREATEST and threatens the patient's 
 life on account of loss of blood. LEUCORRHEA often appears in 
 the inter-menstrual period on account of the pelvic congestion. 
 
 Pain is present in the form of a backache or dysmenorrhea. 
 If it is a submucous form of tumor, the pain will resemble labor 
 pain, since the uterus is contracting in its effort to expel the for- 
 eign body, which is, in this case, the tumor. The pain is brought 
 on by the tumor becoming pedunculated, the pressure on the 
 cervix exerted by it causes impulses to be generated which bring 
 on the uterine contractions. It is very simliar to labor. A BODY 
 
 * 
 
 to be expelled, an OBSTRUCTION to overcome, and a FORCE with 
 which to expel. The same mechanism is at work as in normal 
 labor and the suffering is often a great deal worse. 
 
 The BACKACHE is found most often in the upper portion of 
 the sacrum and lower lumbar region. The increased weight of the 
 uterus causes a sensation of discomfort, which is described as a 
 fullness or weight in the pelvis, or a "dragging down" sensation. 
 This pressure on the nerves produces pains in the limbs, sometimes 
 sharp or shooting, sometimes that of weight or pressure. Traction 
 on the various ligaments produced by the increased weight of the 
 tumor, causes the backache, which is almost unbearable in some 
 cases.
 
 TUMORS OF THE UTERUS. 303 
 
 Pressure on the bladder causes FREQUENT MICTURITION. 
 Pressure on the neck of the BLADDER may produce symptoms of 
 cystitis, indirectly caused by the retention of the urine. Pres- 
 sure on the ADJACENT vessels produces HEMORRHOIDS and VARI- 
 COSE VEINS of the limbs. Pressure on the RECTUM, produces 
 tenesmus. constipation, or a diarrhea if there is a congestion of 
 the mucous membrane of the bowels. Pressure on the URETERS 
 leads to kidney trouble, such as hydronephrosis or albuminuria. 
 Pressure on the UTERUS results in displacement, this being in the 
 direction of least resistance. STERILITY is usually present, 
 sometimes as a cause, sometimes as a symptom. ABORTION may 
 be induced by the presence of the tumor and labor at term ser- 
 iously complicated, either as a result of the mechanical obstruc- 
 tion or post-partum hemorrhage. 
 
 PHYSICAL SIGNS. In the case of large tumors, no diffi- 
 culty will present itself in making a correct diagnosis, since 
 the results obtained by inspection, vaginal examination, abdominal 
 palpation and conjoined manipulation will be so decided, that 
 they will definitely settle the character of the case. Inspection 
 will show enlargement of the abdomen; this not being symmetri- 
 cal in a majority of cases. ABDOMINAL PALPATION in a typical 
 case discloses a large, hard, solid mass, though in exceptional 
 cases it may be soft. Sometimes this tumefaction may closely 
 resemble pregnancy, but there will be the absence of the usual 
 indications of pregnancy. In cases of pregnancy in which the 
 abdomen is very much enlarged, QUICKENING and the FETAL 
 HEART beat can be elicited, thus diagnosing the case. If irregular 
 hard lumps are found it is a good diagnostic sign of fibroid tumors. 
 In the vaginal examination the tumor, if on the ANTERIOR WALL, 
 can be felt through the anterior fornix as a hard irregular mass. 
 This enlargement is diagnosed from the fundus by locating the
 
 304 DISEASES OF WOMEN. 
 
 fimdus in some other part of the pelvis; also it is harder and is 
 accompanied by menstrual disturbances such as menorrhagia. 
 If the tumor is on the POSTERIOR wall it can be felt in the pos- 
 terior fornix or be outlined by rectal examination. By using the 
 bimanual method, the SIZE, LOCATION and density of the tumor 
 can be learned. The uterine canal is elongated, which can be 
 learned by the use of a sound. This is not to be recommended on 
 account of the danger of bringing on an inflammation or hem- 
 orrhage. The external os is enlarged, sometimes patulous, and 
 the cervix softened. In other cases the cervix is rim like, and the 
 walls quite thin. The entire uterus is found prolapsed in the 
 typical case, but in large tumors and unusual cases, there is 
 ascent. 
 
 DIFFERENTIAL DIAGNOSIS. A very large fibroid tumor 
 may be MISTAKEN FOR PREGNANCY. It can be DIAGNOSED from 
 normal pregnancy by the ABSENCE OF THE USUAL INDICATIONS 
 OF PREGNANCY. In extra-uterine forms of pregnancy the diag- 
 nosis is more difficult. The character of the enlargement, his- 
 tory, growth and symptoms must be considered. In both extra- 
 uterine pregnancy and fibroids, there is hemorrhage and both 
 form a mass about or near the uterus. In TUBAL GESTATION the 
 tumor is quite SENSITIVE with colicky pains occuring at irregu- 
 lar intervals. Fibroids are not tender, and except in the sub- 
 mucous type, there are no colicky pains. When rupture of the 
 sac in ectopic pregnancy takes place, there are intense lancinat- 
 ing pains and severe shock. In fibroids the pain is a pressure one, 
 hence not lancinating, but constant and aching. 
 
 In normal pregnancy the enlargement at first is symmetri- 
 cal, the os patulous and the cervix soft. Amenorrhea is pres- 
 ent instead of menorrhagia, as in fibroids. In FIBROIDS the en- 
 largement is frequently IRREGULAR, and os not necessarily patu-
 
 TUMORS OF THE UTERUS. 305 
 
 lous unless there is a great deal of inflammation and the growth 
 very slow. If there is any doubt as to whether the case is one of 
 pregnancy or fibroid tumor, wait; a few months will telL AT 
 LEAST AVOID RADICAL TREATMENT. Mistakes in diagnosis have 
 been made, are being made, and will be made as long as there are 
 physicians and patients, UNLESS CARE is EXERCISED. 
 
 The fibroid TUMOR is DIAGNOSED from a DISPLACEMENT OP 
 THE UTERUS, such as a flexion, by its size, consistency, it being 
 more dense, by its irregularity and by finding the fundus by the 
 bimanual method. It is DIAGNOSED from CANCER by the AGE, it 
 appearing before the menopause, absence of laceration, this being 
 a common cause of cancer; absence of odor, a slower hemorrhage, 
 it being sudden in cancer, absence of constitutional symptoms 
 such as emaciation and the cancerous cachexia and the character 
 of discharge, it being first of a watery, then of a purulent nature 
 in cancer. Sometimes in an incarcerated polypus or one in which 
 the pedicle has been suddenly twisted, there will be some of the 
 symptoms of cancer, but can be diagnosed by locating the tumor 
 and noting its size, shape and consistency. 
 
 An impacted bowel may be mistaken for a tumor, but this 
 should not occur if the symptoms of an impaction are remembered 
 and the shape, size and consistency of the tumor be noticed. A 
 case of fibroid tumor was recently brought to the A. T. Still In- 
 firmary which had been diagnosed as an impaction, and the pa- 
 tient had exhausted the supply of purgatives which had been 
 prescribed by the regular physicians. The pressure of the tumor 
 produced constipation and impaction, and the cause was over- 
 looked on account of the symptoms. 
 
 A PARTIALLY INVERTED uterus may at first be diagnosed as 
 a pedunculated fibroid, but the history, symptoms, absence of 
 
 the fundus of the uterus in the pelvic cavity, felt as a round, not 
 20
 
 306 DISEASES OF WOMEN. 
 
 as an indented body as ascertained by abdominal examination, 
 will clear up the diagnosis. An ovarian or uterine cyst is rec- 
 ognized by the fluctuation, softness of the tumor, rapid growth and 
 absence of arterial hemorrhage during menstruation. 
 
 PROGNOSIS. The prognosis as to a cure, depends upon the 
 LENGTH of standing of the case, degree of DENSITY and SIZE of 
 tumor, mode of onset, age of patient, and the lesions found. If 
 the case is of short duration, and is NOT OP A FIXED SIZE, that is if 
 
 it GETS SOFTER and LARGER AT TIMES, PROGNOSIS IS FAVORABLE. 
 
 If it is a solid tumor of slow GROWTH the size of a croquet ball, 
 the prognosis is unfavorable. If the onset is sudden, and tumor 
 is of rapid growth and soft and the patient is near the menopause 
 the prognosis is more favorable. If a marked lesion is found 
 and the case of not too long standing, a cure is probable. I have 
 taken cases in the early stages of the growth and have stopped 
 the progress and in some cases have even cured them. If the 
 patient is near the menopause the prognosis is favorable regard- 
 less of the character of the tumor since in a great many cases it 
 undergoes spontaneous absorption at that time. If it occurs 
 during gestation it grows very rapidly on account of the in- 
 creased vascularity and in some cases it will undergo atrophy 
 during involution of the uterus. They seldom end fatally but 
 are very chronic, causing the patient to suffer, at least until the 
 menopause is reached. 
 
 The prognosis, as to RELIEVING THE SYMPTOMS, is FAVOR- 
 ABLE. By osteopathic treatment the pressure symptoms, hem- 
 orrhage and the various aches can be lessened unless the case is 
 a very unusual one. 
 
 TREATMENT. The question is often asked whether a 
 fibroid tumor can be cured by osteopathic treatment. I will 
 answer by giving results of some cases treated at the A. T. Still
 
 TUMORS OF THE UTERUS. 307 
 
 Infirmary. Cases of short duration and tumors that were soft 
 and not very large, HAVE EITHER BEEN CURED, or the PROGRESS 
 of their GROWTH STOPPED in every case that I have seen in which 
 the patient ALLOWED us AT LEAST six MONTHS TREATMENT. In 
 cases in which there was a GREAT DEAL OP FIBROUS TISSUE, of 
 LONG STANDING and necessarily very hard, and as large as the 
 two fists, personally, I HAVE NOT SEEN ONE in which the tumor 
 was absorbed, but in most cases the symptoms were wholly or 
 partially relieved. Dr. C. E. Still, who has treated more cases 
 of fibroid tumors than any other osteopathic physician, reports 
 cures in many of the above described cases. He usually insists 
 upon the patient remaining under his care FOR ONE YEAR before 
 he consents to take the case and promise much. Very few cases 
 respond readily, that is, few changes occur in a few months treat- 
 ment and the patient often becomes discouraged at the end of 
 that time and gives up the treatment, saying that osteopathy is 
 a failure; whereas IF THEY HAD CONTINUED UNDER TREATMENT 
 
 FOR A LONGER TIME SOME CHANGE FOR THE BETTER WOULD HAVE 
 
 BEEN NOTED. Goodall says that " solid uterine fibroids of a stony 
 hardness of several pounds weight will occasionally disappear," 
 and he cites forty cases in support of his statement. 
 
 Emmett also reports similar cases of spontaneous absorp- 
 tion. IF SUCH RESULTS OCCUR SPONTANEOUSLY, why will they not 
 occur oftener and more rapidly under osteopathic treatment, 
 which is one of adjustment, hence helpful to the natural forces. 
 I firmly believe that in the cases in which there is a failure, 
 the fault is usually with the physician, and that we lack the 
 requisite skill in cases in which we fail. OSTEOPATHY, if 
 properly applied, WILL CURE ANY case of tumor that is curable. 
 In the CURATIVE treatment the BONY LESIONS that are found, 
 are corrected. This is the fundamental and primary step. By
 
 308 DISEASES OF WOMEN. 
 
 the correction of these lesions that disturb the circulation, the 
 nutrition to the uterus is re-established and that of the tumor is 
 shut off and soon absorption begins. It can be compared to the 
 treatment of a goiter or an enlarged tonsil. The absorption 
 follows the correction of the lesion unless there is too much fi- 
 brous tissue already formed, which is very slow of absorption. 
 The question arises, is the absorption produced by increasing 
 the arterial blood supply or lessening it? I think it is produced 
 by restoring a normal circulation of blood to and from the organ. 
 Since nature tends toward the normal, any little help that can 
 be given, increases the POWER of nature to throw off foreign ele- 
 ments and restore the natural circulation to and around the 
 part. As mentioned before, if this disturbing factor, the lesion, 
 BE CORRECTED, nature, unless the process has gone too far, WILL 
 CERTAINLY ASSERT HERSELF and restore the parts to their normal 
 condition. In addition, the tumor should be loosened and soft- 
 ened by lifting, or pushing it out of the pelvis, in order to free 
 the circulation. This can be done by working directly over the 
 tumor through the abdomen or by the use of Dr. Still's wire re- 
 positor. By doing this every few days the tumor, after awhile, 
 becomes softened, pressure on the blood vessels and other neigh- 
 boring structures relieved, and absorption is increased. 
 
 I do not mean by this that the tumor should be massaged. 
 On the other hand I think MASSAGE is CONTRAINDICATED. The 
 abdominal treatment should be confined to a LIFTING UP ONE, 
 which tends to relieve the pressure and free the circulation. The 
 local application of drugs will not do this, nor will the internal 
 administration of same do any good. 
 
 The IDEAL way of treating fibroids according to the author's 
 notion, based upon enteroptosis as the most important of the 
 causes, is to PUT THE PATIENT TO BED AND KEEP HER THERE FOR
 
 TUMORS OF THE UTERUS. 309 
 
 SEVERAL MONTHS, the length of time depending on the size and 
 density of the tumor. The prone posture relieves pelvic con- 
 gestion, which UNDOUBTEDLY IS THE IMPORTANT, IMMEDIATE Or 
 
 exciting CAUSE of tumors. Coupling with the rest treatment, 
 an ABDOMINAL ONE, directed to the RELIEVING OF THE IMPACTED 
 pelvis and one directed at the correction of the spinal lesions, 
 a cure would seem more probable than under the ordinary cir- 
 cumstances. 
 
 Since the above treatment in the average case is out of the 
 question, the WEARING OF A SUPPORT is to be advised, if the 
 tumor is very large and heavy. "The Old Doctor" has devised 
 a belt so arranged that if properly applied, the enteroptosis can 
 be considerably relieved, thus improving pelvic circulation. 
 
 In cases OF EXTREME BACKACHE accompanying the tumor, 
 PRESSURE over the PERINEUM with the palm of the hand, will 
 temporarily relieve the pain. The patient should be kept 
 from standing, or walking very much, since this increases 
 the pressure or tension, thus making the condition worse. EVERY- 
 THING THAT PRODUCES PELVIC CONGESTION SHOULD BE AVOIDED 
 
 if possible to do so. Constipation, coitus, tight clothing, stand- 
 ing on the feet for several consecutive hours, walking or vigorously 
 using the limbs in any way, such as running a sewing machine, 
 all tend to exaggerate the already existing pelvic congestion. 
 Especially at the menstrual period should the above mentioned 
 things be avoided, and if possible keep the patient in a reclining 
 posture. The knee-chest position should be assumed quite often, 
 since this relieves in part at least, the congestion of the pelvic 
 viscera. 
 
 In cases of menorrhagia in which the flow is arterial in 
 character, the patient should be put to bed with the foot of the 
 bed elevated, and treatment given to contract the uterus. This
 
 310 DISEASES OF WOMEN. 
 
 is ordinarily accomplished by strong stimulation over the lower 
 lumbar region and clitoris. Hot injections, ice packs or as- 
 tringent solutions of sulphate of iron, alum or witch hazel, can 
 be introduced directly into the uterine cavity, when the other 
 methods fail. On account of its action on the smaller blood 
 vessels their use seldom fails to stop or check the hemorrhage. 
 The custom of packing the vagina is not very successful, it only 
 results in preventing external hemorrhage while often the in- 
 ternal, still continues. 
 
 OPERATIONS. About the first thing that a surgeon ad- 
 vises in the case of a fibroid tumor, is an operation, and I think 
 many lives have been sacrificed on account of a TOO FREE USE of 
 the knife. I know of a great many cases in which hysterectomy 
 was performed by eminent surgeons for a very small fibroid 
 that was causing very little inconvenience. In a large per cent, 
 of these cases the operations were successful, but the patient died. 
 WHY RISK A PATIENT'S LIFE BY OPERATIONS WHEN THE SYMPTOMS 
 ARE NOT SEVERE NOR POINT TO A FATAL TERMINATION? 
 
 The osteopath believes in surgery; it is a distinct separate 
 science, but it should be a last resort after other methods have 
 failed. Operations for the removal of fibroid tumors are rec- 
 ommended if the case can not be cured by osteopathic treat- 
 ment, after a fair trial has been given. If the symptoms are 
 severe enough and cause the patient constant pain, or if the pa- 
 tient is not near the menopause an operation is usually advisable. 
 They are not advised if the tumor is small, and the symptoms 
 mild, or if the patient is near the menopause, for in the majority 
 of cases the growth will stop or the tumor will undergo atrophy 
 at that time. For the different kinds of operations, and the 
 methods used, a work on surgical gynecology should be con- 
 sulted.
 
 TUMORS OF THE UTERUS. 311 
 
 Curettage is sometimes performed by surgeons in cases of 
 the submucous form of fibroid tumors, by means of the sharp 
 curette as shown in Fig. 100. In this way the lining membrane of 
 
 FIG. 100. The sharp uterine curette. 
 
 the uterus with a part of the tumors are removed. THIS SHOULD 
 NOT BE RESORTED to until osteopathic treatment has failed, on 
 account of the hemorrhage, danger of infection, and on account 
 of the small amount of relief that usually follows the operation. 
 
 In other types of fibroids, although marked hemorrhage 
 exists, curettage is of no value. A great many cases of sub- 
 mucous fibroids have been reported me as cured by the ordinary 
 osteopathic treatment. 
 
 The use of ELECTRICITY is advised by some. Hirst says 
 that he was appointed by the Philadelphia County Medical 
 Society, as one of a committee of three "to investigate this form 
 of treatment for fibroids." He says "In three years time not 
 a single case was presented of a tumor reduced in size by elec- 
 trical treatment." If beneficial at all it is only palliative; such 
 a treatment does not remove causes. A PERVERTED CONDITION 
 of the STRUCTURES of a part of the body exists, which must be 
 corrected before a cure is completed. 
 
 POLYPI. A polypus is a pedunculated tumor attached to 
 a mucous membrane. Those found in the uterus are of the 
 mucous or fibroid variety, the latter being the more common. 
 The FIBROUS POLYPI spring from the muscular wall of the uterus, 
 most commonly from the body since that is the usual seat of 
 fibroid tumors. They are similar to fibroid tumors as to con- 
 sistency, appearance and structure; in fact they are fibroid tu-
 
 312 
 
 DISEASES OF WOMEN. 
 
 mors with a pedicle. In SIZE they vary from that of the end of 
 the finger to that of a goose egg or even larger. As they en- 
 large the uterine cavity is dilated and the pressure exerted on 
 the cervix sets up uterine contractions which, in a great many 
 cases cause their expulsion. They are sparingly vascular but 
 are congested and enlarged during menstruation. This en- 
 largement increases the uterine contraction and is a favorable 
 
 FIG. 101. Different forms of uterine polypi, with the vagina 
 and part of the cervix removed. 
 
 time for their expulsion on account of the dilated condition of 
 the os uteri. After it has been expelled from the uterus, it still 
 retains connection with the uterus by a long pedicle. 
 
 A mucous polypus is soft and pulpy and rarely reaches a
 
 TUMORS OF THE UTERUS. 313 
 
 size larger than that of an almond. They are developed from 
 the mucous membrane lining the cervix and usually appear in 
 groups. They are extremely vascular and bleed readily on irri- 
 tation. 
 
 SYMPTOMS. Hemorrhages are the first symptoms on 
 account of the location of the tumor, it being on or near the 
 mucous membrane. It like hemorrhage from fibroid tumors, 
 begins as a menorrhagia, but afterward it becomes irregular and 
 assumes the form of metrorrhagia. It comes from the con- 
 gested mucous membrane and from the polypus itself. 
 
 Leucorrhea is present as a result of the congestion of the 
 endometrium. Dysmenorrhea is very marked in cases in which 
 the polypi cause pressure on the cervix. It is similar to, or 
 even worse in some cases, than parturition. In other cases 
 the presence of a polypus has caused various reflex symptoms 
 of pregnancy, such as pigmentation of the breast and morning 
 sickness. STERILITY is caused partly by the obstruction pro- 
 duced by the polypus and partly by the diseased condition of 
 the endometrium which accompanies these cases; this not per- 
 mitting of a secure attachment of the ovum to the uterine wall. 
 
 DIAGNOSIS. If the external os is so dilated that the tu- 
 mor protrudes into the vagina, it can be recognized by the finger 
 on vaginal examination or by inspection, a speculum being used. 
 Then by encircling the cervix with the finger and examining the 
 body through the fornices the pedicle, and the size of the tumor 
 can be readily ascertained. By the use of a speculum, the tu- 
 mor will appear of a bright color, which contrasts with the dark 
 red color of the cervical mucous membrane. Sometimes it is 
 advisable to introduce the finger directly into the uterus, thus 
 exploring the uterine cavity, the polypus then can be plainly 
 felt, making the diagnosis certain.
 
 314 DISEASES OF WOMEN. 
 
 The polypus may be mistaken for a partial INVERSION es- 
 pecially if very much hemorrhage is present. The presence of 
 the fundus in the pelvic cavity as ascertained by bimanual pal- 
 pa'tion, the slowness of the onset, the consistency of the tumor, 
 it being harder, and the shape and appearance of the polypus 
 are sufficient to diagnose a polypus from an inversion of the 
 uterus. 
 
 The prognosis as to danger to life, depends upon the 
 amount, and character of the hemorrhage. On account of its 
 location a polypus may set up a great deal of hemorrhage which 
 may not only produce anemia but fatal symptoms. The prog- 
 nosis as to RELIEF without an operation depends upon the char- 
 acter of the polypus, and should be guarded. The operation for 
 the removal of the polypus is simple and seldom terminates 
 seriously if performed properly. 
 
 TREATMENT. The treatment of polypi depends upon then- 
 size, where they are attached, length of pedicle and amount of 
 hemorrhage. If the tumor is small or of a submucous variety 
 it can easily be cured by osteopathic methods. This is accom- 
 plished by directing more arterial blood to the uterus and by 
 causing uterine contraction. These contractions will in most 
 cases produce expulsion of the tumors. The TREATMENT to 
 accomplish this, should be in the lower lumbar region, or at the 
 sacro-iliac synchondroses, since the LESIONS affecting the uterine 
 circulation are found at these points. 
 
 TORSION is sometimes used. The polypus is grasped either 
 by the hands or forceps and twisted. Removal is advocated 
 in most cases if the polypus is large, or if it is completely obstruct- 
 ing the os, and causing marked dysmenorrhea. 
 
 CANCER OF THE UTERUS. Cancer is a MALIGNANT DIS- 
 EASE which attacks most frequently, the cervix uteri, mammary
 
 TUMORS OP THE UTERUS. 315 
 
 glands, and face. It takes its name from the word meaning 
 CRAB, on account of its tentacles radiating in every 
 direction for quite a distance, sometimes six or eight 
 inches, thus making it a very deeply seated disease. Carcinoma 
 is the term commonly used for true cancer, although sarcoma 
 and malignant adenoma are commonly called cancers. They 
 undermine the constitution and in most cases rapidly lead to 
 death, hence are classified as malignant. It is above all other 
 diseases the one that a woman dreads, and rightly too, since its 
 termination is so fatal and its course so painful and distressing. 
 Even if extirpated, it tends to recur in a worse form and hastens 
 the death of the patient. 
 
 VARIETIES. There are three common VARIETIES of cancer, 
 viz: the MEDULLARY or ENCEPHALOID, the SCIRRHUS and the 
 EPITHELIOMA. They differ in degree and in the elements of 
 which they are composed. The encephaloid is the softest and it 
 is the most fatal, that is, its progress is most rapid and produces 
 death soonest. The scirrhus is hard on account of the pre- 
 ponderance of fibrous tissue, but is rarely found attacking the 
 uterus. The epithelioma attacks the equamous epithelium of 
 the cervix and causes a typical multiplication of the cells which 
 invade the deeper tissues. Another classification is made ac- 
 cording to the part of the uterus affected, into cancer of the 
 vaginal portion, cancer of the cervix and cancer of the body of 
 the uterus. 
 
 CAUSES. The causes of cancer are not very well known 
 although certain constant factors are found accompanying the 
 disease. HEREDITY has something to do with causing cancer, 
 but unless acting in conjunction with other causes it is not suffi- 
 cient of itself to set up a cancerous process. It will act as a pre- 
 disposing cause, that is, it may weaken the pelvic organs and
 
 316 DISEASES OF WOMEN. 
 
 then the exciting cause can the more easily and readily act. 
 
 AGE has considerable influence in the production of the dis- 
 ease. It occurs most frequently between the ages of forty and 
 sixty, it seldom occuring before the menopause. At this age 
 the vital powers are lessened, this favoring the attack. Any- 
 thing which tends to lower the vitality increases the liability to 
 the disease. REPEATED pregnancies are important causes, can- 
 cer being most frequently found in multipara who have borne at 
 least five children, judging from the statistics on the subject. 
 LACERATION of the cervix is the most important of the exciting 
 causes, and I doubt if cases of cancer of the cervix are found 
 without being preceded by a bruise or a laceration. This causes 
 a constant irritation, a congestion and a weakening, followed by 
 a lowering of the vitality of the cervix. It is similar to an epithe- 
 lioma of the lip which is caused by a jagged tooth or the pro- 
 verbial Irishman's pipe. 
 
 Cancer of the breast commonly arises in a similar way. 
 First, a BRUISE, a local swelling, patient getting scared and then 
 irritates the part by frequent manipulation, the surgeon's knife 
 and then the formation of the cancer proper. 
 
 The CERVIX bears the brunt of coition and parturition. It 
 is also bruised by the use of instruments introduced into the 
 uterine cavity. If the predisposition is there, whether it be 
 heredity or otherwise, the irritation resulting from the bruising 
 in some cases results in the cancerous formation. I should re- 
 gard cancers as caused by a disturbance of the LYMPHATIC and 
 VENOUS circulation, but principally by a disturbance of the 
 lymphatic. IT is THE RESULT OF AN INJURY OF THE LYMPHATICS, 
 and from this results the watery discharge. The disturbance 
 to the blood supply is shown by the fungus-like appearance 
 of the new growth, and the raw and angry appearance of the
 
 TUMORS OF THE UTERUS. 317 
 
 cervix. This vascular disturbance is produced by the local irri- 
 tation which had followed the laceration, or else it is due to a 
 lesion affecting the vaso-motor centers of the cervix. 
 
 The LOCAL INJURY is not sufficient to cause the disease, or 
 else every woman who has been lacerated or had the cervix 
 bruised would have a cancer. There must be something else 
 in addition, and the bony lesions impinging on the nervous con- 
 nection with the uterus, is to me a very plausible cause. It is 
 the more plausible WHEN CASES ARE TAKEN and CURED, which 
 have been diagnosed as cancers, by correcting these lesions. In 
 these cases the pelvic circulation was improved and the symp- 
 toms either abated or in some cases, entirely disappeared. After 
 all, the cause of cancer is a mystery to physicians, there being 
 various THEORIES, some of which attribute it to various imagi- 
 nary micro-organisms, but no proven theory as yet has been 
 found. To the osteopath, the disturbances of the lymphatic 
 and venous circulation are the most important causes, and all 
 his efforts should be directed to restore the normal flow of lymph 
 and blood to and from the part. 
 
 SYMPTOMS. The EARLY SYMPTOMS are few and mild, not 
 prompting the patient to seek the advice of a physician. This 
 is one reason why it is so hard to cure, since it is rare to get a 
 case in the early stages. At first the symptoms are local but 
 soon begin to affect the constitution and undermine the general 
 health. 
 
 Hemorrhage is one of the first local symptoms noticed. 
 It in patients who have not reached or passed the menopause, 
 like hemorrhage found in fibroid tumors, appears first as a men- 
 orrhagia. The patient on account of her age, she being at or 
 near the menopause, usually attributes this to the change of life, 
 thinking it to be one of the attendant symptoms. She finally
 
 318 DISEASES OF WOMEN. 
 
 consults a physician, if it becomes too profuse and a well devel- 
 oped cancer is frequently found. In other cases the hemor- 
 rhages comes on irregularly and independent of the menstrual 
 period. This comes from rupture of the dilated vessels and from 
 an extension of the ulcerative process by which the blood ves- 
 sels are eroded. It may appear suddenly after an exertion, as 
 straining at stool or after coition. 
 
 With the progress of the disease, the HEMORRHAGE increases, 
 it coming on in gushes and in some cases threatening the pa- 
 tient's life. Sometimes the patient tells you that THE MEN- 
 STRUAL FLOW NEVER ENTIRELY CEASES. This is an important 
 point if found in a patient which is in the change of life, or which 
 has just passed the menopause. Since cancer appears most fre- 
 quently just after the menopause, any unusual hemorrhage 
 should be properly examined as to its cause and source, since 
 THE EARLIER THE DISEASE is RECOGNIZED the greater the prob- 
 ability of a cure. 
 
 The DISCHARGE of carcinoma is of a watery nature and of a 
 very FETID ODOR after ulceration has set in. I have examined 
 patients in the early stages of the disease by means of a speculum, 
 in which drops of water could be seen to collect on the cervix. 
 The amount varies, but usually a drop is secreted every few min- 
 utes, so that after awhile there is quite a marked watery dis- 
 charge. This is a symptom which is seldom found in other 
 uterine diseases and is regarded as one of the important indica- 
 tions of cancer. There is no odor connected with the discharge 
 in the early stages, which discharge is most frequently found 
 accompanying the papillary epithelioma or the so-called "CAUL- 
 IFLOWER" EXCRESCENCE. After there is ulceration the discharge 
 becomes more offensive and increases in amount as the disin- 
 tegration becomes more marked. The odor at this stage is VERY
 
 TUMORS OF THE UTERUS. 319 
 
 NAUSEATING, markedly penetrating and clings to the examining 
 finger for sometime, regardless of the efforts to remove it. The 
 discharge is called CARCINOMATA ICHOR or "CANCER JUICE." 
 
 Pain is not an important symptom hi the early stages of 
 cancer, but in the later stages BECOMES VERY CONSTANT. After 
 ulceration begins, sharp lancinating pains are felt in the pelvic 
 region and sometimes shooting through to the back and re- 
 flected down the limbs. Sometimes it is a dull gnawing pain 
 which is located in the small of the back or deep down hi the pel- 
 vis. Occasionally this pain is reflected to the mammary glands, 
 setting up a reflex functional disturbance of the glands. Local 
 peritonitis, which accompanies nearly all those cancerous condi- 
 tions of the uterus, is also productive of pain which is localized. 
 The adhesions which are present, prevent the diffuse form of 
 peritonitis in most cases. 
 
 The disease may extend to the neighboring organs, pro- 
 ducing ulceration or other disturbance in them. The bladder 
 becomes irritable, frequent micturition is present, and in some 
 cases cystitis, and painful urination. The kidneys on account 
 of the pressure on, or the extension to them of the disease from 
 the uterus, are frequently affected. There may be hydronephro- 
 sis, uremia or organic disturbances of the kidney. 
 
 CONSTIPATION* is present on account of the PAIN associated 
 with defecation, DRYNESS of the feces resulting from the watery 
 discharge, and WEAKNESS of the expulsive forces on account of 
 the extension of the disease to the rectum. Diarrhea follows in 
 some cases in which the rectum is irritated by the invasion of 
 the cancer. The lymphatic glands in the lumbar region are 
 enlarged and tender, and care should be exercised in treating the 
 abdomen lest there be bruising or injury of these glands. 
 
 GENERAL SYMPTOMS. In addition to the local symptoms
 
 320 DISEASES OF WOMEN. 
 
 mentioned, there are CERTAIN GENERAL symptoms which are 
 secondary to the local trouble. The most marked are: EMACIA- 
 TION and GENERAL DEBILITY. In the early stages the patient 
 may be apparently healthy, but after there is much ulceration, 
 the skin becomes anemic and of a straw color; there is PROGRESSIVE 
 LOSS OF FLESH and the patient has a CAREWORN APPEARANCE. 
 These facial symptoms are called CANCEROUS CACHEXIA or can- 
 cerous facies. The APPETITE is deranged and there is anorexia, 
 nausea and sometimes vomiting. There is sleeplessness, anxiety, 
 anemia and a general loss of energy. 
 
 PHYSICAL SIGNS. In making a local examination it is 
 well to protect the finger by coating it over with glycerine. This 
 lessens the danger of infection and assists in the removal of 
 the fetid odor which clings to the finger. 
 
 In a typical case, the inside of the cervix is soft and FRIABLE, 
 while the rim of the cervix is hard. The mucous membrane is 
 found to be partially inverted, which gives it a rough or CAULI- 
 FLOWER appearance. There is proneness to hemorrhage on the 
 least irritation by the examining finger, and particles of the 
 GROWTH CAN BE READILY BROKEN off with the finger nail. The 
 rough irregular mass is felt and with the spculum, the cauliflower 
 fundus-like bleeding tumor can be seen. Particles are frequently 
 sloughed off and discharged PER VAGINA, that is, if it is friable. 
 
 The microscopic examination reveals a fibrous stroma with 
 alveoli which contain irregular cells of an epithelial type. In 
 cases of advanced standing in which the vaginal examination is 
 too painful and productive of hemorrhage, a rectal examination 
 can be made. The uterus is felt to be fixed and the cancerous 
 area outlined. A speculum should be used in most cases in 
 which cancer is suspected, since INSPECTION is THE best method 
 by which to diagnose the disease.
 
 TUMORS OF THE UTERUS. 321 
 
 DIFFERENTIAL DIAGNOSIS. The diagnosis of cancer is some- 
 times very hard as it is quite often mistaken for other diseases, 
 or rather it is the reverse, that is, other diseases are MORE FRE- 
 QUENTLY MISTAKEN FOR CANCER. Many cases that come to 
 the A. T. Still Infirmary that had been diagnosed as cancers, 
 turn out to be something else, such as a simple tumor, laceration 
 or ulceration. 
 
 It is diagnosed from fibroid tumors by the HEMORRHAGE; 
 its amount and onset. In fibroid tumors it is gradual in its onset; 
 not so constant nor profuse except in some cases of the sub- 
 mucous variety. In a fibroid there is ABSENCE of a fungus-like 
 mass, of a fetid odor, of FRIABILITY, and the disease appears 
 before the age of forty-five. There is absence of constitutional 
 symptoms and it runs a much more chronic course than in can- 
 cer. The enlargement is different as to size, location and ap- 
 pearance. Fibroid tumors are usually located on the fundus, 
 develop slowly and produce enlargement of the abdomen, while 
 cancers are found on the cervix, develop rapidly and produce 
 no enlargement of the abdomen. A polypus, in which there has 
 been sudden torsion of the pedicle, may be mistaken for a cancer 
 on account of the discharge, odor 'and the hemorrhage. The 
 other symptoms of cancer are absent. On examination of the 
 cervix no growth is found, but on examination of the uterine cav- 
 ity the tumor can be outlined. 
 
 An EROSION or ulceration of the cervix is most frequently 
 mistaken for cancer. Consider the odor of the discharge, length 
 of standing, constitutional symptoms, and amount of pelvic 
 disturbances. On examination of the ulcer it is not like a cauli- 
 flower in appearance, not friable and is localized and yellowish 
 in color, while cancer is red. 
 
 A LACERATION that has not healed, may give rise to symp-
 
 322 DISEASES OF WOMEN. 
 
 toms of cancer, but from history, absence of characteristic cancer 
 symptoms and locating the rupture of the cervical wall by the 
 examining finger and by use of the speculum, it can be easily 
 differentiated from cancer. In laceration, the splits in the cer- 
 vix radiate from within outward and are regular, but in cancer the 
 fissures are irregular, sometimes running crosswise of the cervix. 
 
 To SUMMARIZE the diagnostic symptoms of a cancer, note the 
 RAPID PROGRESS of the disease, AGE of patient, she being above 
 forty years of age, evidences of HEREDITY, presence of the char- 
 acteristic symptoms and SIGNS OF MALIGNANCY such as pain, 
 hemorrhage, fetid discharge, pelvic and reflected pains, FIXATION 
 of the body of the uterus, INVOLVEMENT of adjacent parts, tend- 
 ency to resist treatment and to recur after removal, and the CACHE- 
 TIC appearance of the patient. The physical signs that are found 
 by examination with the finger and speculum, evidences of metas- 
 tasis and growths elsewhere, and the microscopical appearance 
 of portions of the cancerous growth make the diagnosis sure. 
 
 PROGNOSIS. The prognosis in cases of true cancer is very 
 unfavorable, both as to cure and relief. In cases of supposed 
 cancer it is favorable. I have seen cases or conditions that were 
 diagnosed as cancer which were cured, and on this account, if 
 the case is taken in the very early stages, there is a chance of it 
 not being a cancer and can be eventually cured. Consider this 
 in making a prognosis since you should be very guarded as to the 
 outcome of the disease. Never pronounce a case as one of can- 
 cer until you are sure of your diagnosis, for the patient will likely 
 get worse from the very thoughts of having the dreaded disease. 
 
 If it is one of TRUE CANCER, its course is rapid and death 
 usually results within two years, sometimes a great deal sooner, 
 especially in the encephaloid variety. Under osteopathic treat- 
 ment a great many cases of SUPPOSED CANCER have been cured,
 
 TUMORS OF THE UTERUS. 323 
 
 but I have never seen a case of a truly well developed cancer cured. 
 In the later stages the pain and suffering can be markedly re- 
 lieved, and on this account if on no other, the treatment is a 
 wonderful advancement on the usual methods. 
 
 MODES OF DEATH. The patient may die from hemorrhage, 
 but this is rare. CANCER USUALLY KILLS BY GRADUAL EMACIA- 
 TION AND MALNUTRITION. There exists DISINTEGRATION OF THE 
 
 RED BLOOD CORPUSCLES which lowers the vitality of the blood 
 and produces the hematogenous form of jaundice. Complica- 
 tions such as peritonitis, bowel troubles, emboli lodging in the 
 various parts of the body, causing secondary cancerous forma- 
 tions, all help to hasten the fatal end. 
 
 TREATMENT. The surgical treatment is, removal of the 
 cancerous mass JUST AS SOON AS POSSIBLE. If in early stages, 
 unless it is entirely removed, the operation only hastens the 
 progress of the disease by lowering the vitality of the tissues. A 
 great many cases of supposed cancer are helped to be developed 
 into true cancer, and that very rapidly, by attempt at removal. 
 If it were possible to completely remove the diseased portion, an 
 operation might be successful, but on account of the tentacles 
 and branches running out into the adjacent structures for several 
 inches, it makes a complete removal almost impossible. If oper- 
 ated on in the later stages the cure is still more improbable and 
 for these reasons an operation is contraindicated. The opera- 
 tion usually performed is one of HYSTERECTOMY, either vaginal 
 or abdominal. 
 
 The osteopathic treatment is one directed to build up the 
 quality of blood and to improve the circulation through the 
 affected area. This is accomplished by treatment along the 
 lumbar and sacral regions. I have a record of several cases that 
 were diagnosed as cancer that were cured, in which the treat-
 
 324 DISEASES OF WOMEN. 
 
 ment was almost entirely applied to the lumbar and sacral re- 
 gions. In these there were the usual symptoms of cancer, the 
 irregular growth, fetid odor, hemorrhage and pain. 
 
 If the discharge is irritating or of a very fetid odor, a carbol- 
 ized douche should be given. 
 
 The palliative treatment consists of inhibition over the sen- 
 sory nerves connected with the uterus. These can be reached 
 through the lower lumbar and sacral regions. The pain and 
 aching can be relieved, but only temporarily, since no permanent 
 results follow that kind of treatment. Various cancer "pastes" 
 and "sure cures" are advertised, but have very little effect on 
 the course of the disease except that they so often make it worse. 
 
 Sarcoma of the uterus is a malignant tumor which differs 
 from carcinoma in that it belongs to the connective tissue group 
 and is of an embryonic type. It rarely, as compared with car- 
 cinoma, attacks the uterus. It may appear at any age but occurs 
 most frequently at or immediately after the menopause. It, un- 
 like cancer, attacks the fundus most frequently. The cause of 
 the disease is unknown but is supposed to be similar to that pro- 
 ducing cancer. 
 
 SYMPTOMS. The symptoms are very much like those pro- 
 duced by cancer. The hemorrhage, pain, especially after the 
 disease is well developed, watery discharge and the cachexia or 
 constitutional symptoms are like those of cancer. The ROUND 
 CELL variety is more malignant than cancer, it producing death 
 within a few months. It spreads by way of the blood vessels 
 instead of the lymphatics as we find in cancer. 
 
 SOMETIMES A MYOMA may develop into a sarcoma, if the tu- 
 mor has been bruised or injured to any great extent. FOR THIS 
 
 REASON, CARE SHOULD BE TAKEN NOT TO BRUISE A TUMOR BY A 
 TOO HARD TREATMENT OVER IT OR ELSE IT MAY BECOME MALIG-
 
 TUMORS OF THE UTERUS. 325 
 
 NANT. In some cases the growth becomes rapid, pain severe 
 and termination fatal in a very short time. 
 
 Its diagnosis as to malignancy is based upon the above 
 symptoms, that is, fetid discharge, hemorrhage, pain, rapid pro- 
 gress, and constitutional symptoms. It can be diagnosed from 
 cancer from its position, it being found in the connective tissue 
 of the fundus, also by microscopic examination, since it is com- 
 posed of connective tissue and cancer of epithelial cells. 
 
 The treatment is the same as for cancer. The prognosis is 
 grave. It can be relieved temporarily but a complete cure is 
 rare. 
 
 Sometimes there are cases of sloughing fibroid tumors that have 
 been diagnosed as sarcomata, that were cured by the treatment, 
 but true sarcoma is usually incurable. As in cancer be sure of 
 your diagnosis before telling the patient, because it means all to 
 the patient.
 
 326 PISEASES OF WOMEN. 
 
 LACERATION OF THE CERVIX. 
 
 LACERATION OF THE CERVIX is a rupture of the cervix 
 uteri in one or more places DURING CHILDBIRTH, or from FORCI- 
 BLE DILATATION of the os by means of an instrument. It is a very 
 common condition and one that is productive of a great many 
 symptoms both local and reflex. I have examined case after 
 case of multiparous women in which the symptoms were those of 
 nerve waste, loss of energy, nervousness, hysteria, and in most of 
 them there was a laceration accompanied by subin volution and 
 endometritis. 
 
 It is caused in various ways, but the most important cause is 
 
 MEDDLESOME MIDWIFERY and HASTILY CONDUCTED LABORS. The 
 
 cervix is not fully prepared to dilate sufficiently to transmit the 
 fetal head until the end of the normal period of gestation. If 
 labor is induced or hurried, the cervix instead of stretching as it 
 should, is forcibly torn, but if left to nature, a very few cases of 
 laceration will occur. NATURE never intended that a woman 
 should be lacerated at childbirth. The NATURAL process, if left 
 alone, unless there is a precipitate delivery, or the parts are dis- 
 eased, WILL CAUSE A NATURAL STRETCHING and dilatation, which 
 prevents the tissues from tearing, but sometimes the accoucher 
 thinks he can improve on nature but dismally fails, although the 
 child is born sooner. 
 
 I think the USE OF ERGOT and QUININE or any other drug 
 used to bring on uterine contractions, is to blame as much as any 
 one thing. These drugs cause a contraction of the uterine mus- 
 cles. The fundus being larger and stronger than the cervix con- 
 tracts with GREATER force and forces the fetal head downward
 
 LACERATION OF THE CERVIX. 327 
 
 against the resisting os. Instead of relaxing the muscle fibers 
 of the cervix, it produces a contraction, but this CONTRACTION 
 is OVERCOME by the greater force from above, the contraction of 
 the fundus, and as a result the os is forcibly dilated and conse- 
 quently the constrictor fibers are torn. SUFFICIENT TIME is NOT 
 GIVEN for relaxation, since it takes quite a while in some cases, 
 for those fibers to relax and, as a result, the fibers are ruptured. 
 
 IMPROPER TREATMENTS applied to the uterus WHILE IN THE 
 XOX-PREGNANT STATE, such as the use of the dilator, sound or 
 the application of caustics or astringents, harden the cervical 
 tissues. This retards or hinders dilatation and the tissues tend 
 to tear rather than stretch. 
 
 A TOO RAPID DELIVERY has a similar effect, that is, time is 
 not given for relaxation. HIGH FORCEPS delivery produces 
 laceration in nearly every case. In case of LARGE FETAL head, 
 a RIGID os or any diseased condition of the cervix, there is a lia- 
 bility of laceration, even if precaution is taken. However, the 
 greatest number of cases result from the physician being in TOO 
 GREAT A HURRY. If the labor is slow, something is administer- 
 ed to bring on the labor pains, or if they are feeble he resorts to 
 the use of forceps. In a case of a deformed pelvis sometimes it is 
 impossible to prevent laceration, also in cases in which rapid 
 delivery is necessary, such as placenta previa or breech delivery. 
 
 VARIETIES. A LACERATION usually takes place laterally. 
 If only one side is torn it is called a unilateral laceration; if two 
 sides, a bilateral; if at more than two places it is called a stellate 
 laceration. The laceration varies from a slight tear which heals 
 in a few days, to a complete laying open of the cervical portion 
 of the uterus and extending to the roof of the vaginal vault. In 
 some cases the cervix is literally slit into halves. This leaves a 
 raw open wound which is irritable and gives rise to inflammatory 
 conditions of the uterus and vagina.
 
 328 DISEASES OF WOMEN. 
 
 SYMPTOMS. The immediate symptoms are those of ARTERIAL 
 HEMORRHAGE. It may be very profuse; the quantity depending 
 upon the depth of the tear and the number of vessels injured. 
 The patient will complain of a burning sensation referred to the 
 cervix, also local pain or reflex ache. The lochia usually con- 
 tinues longer than normal and the changes delayed. 
 
 The secondary symptoms are varied. If the patient is 
 strong, it will not affect her for sometime, but if she is weak 
 to begin with, the laceration very soon begins to weaken her 
 more and set up reflex troubles. 
 
 The local symptoms are those of chronic inflammation. The 
 cervix is congested, soft, and the os patulous. The disturbances 
 to the circulation affect secretion as is evident by the leucorrheal 
 discharge. 
 
 Involution of the uterus is RETARDED, this producing a con- 
 dition called SUBINVOLUTION. MENSTRUATION is irregular and 
 the flow usually is increased in amount. The reflex and general 
 symptoms are many, in fact all varieties are found in cases of 
 bad laceration. 
 
 Neuralgia in different parts of the body is sometimes present. 
 It very frequently assumes a form of INTERCOSTAL NEURALGIA 
 or in some cases, NEURALGIA OF THE FIFTH CRANIAL NERVE. The 
 cervix may be very sensitive if in the recent state, and the pain 
 has been compared to that of an ache due to an exposed nerve. 
 Nerve filaments may be caught in scar tissue which is formed, 
 this causing reflected pains. BACKACHE in the lower lumbar 
 and sacral regions is common. The limbs may ache or as many 
 a patient describes it, feel heavy. This is probably due to the 
 INCREASED WEIGHT of the uterus and inflammation of the nerve 
 terminals in the uterus. The pelvic floor is weakened and there 
 is a tendency to a backward and downward displacement of the 
 heavy subinvoluted uterus.
 
 LACERATION OF THE CERVIX. 329 
 
 Reflex troubles are very marked. HYSTERIA in its worst 
 form is found in cases of laceration of the cervix. It causes a 
 disturbance of the nervous equilibrium on account of the con- 
 stant loss of nerve force, and the patient becomes unable to con- 
 trol herself. There will be in some cases a choking sensation, 
 PAIX in, and contraction of, one limb, flatulency, anuria, aphonia, 
 and in many cases, the patient may entirely lose control of her- 
 self and give vent to her feelings by screaming or crying. This 
 forms a SAFETY VALVE by which the excessive pressure is relieved. 
 Again I have seen CATALEPTIC conditions, resulting from lacera- 
 tion, the patient remaining stiff for some hours. The constant 
 loss of nerve force, causes a change in the disposition, the pa- 
 tient becoming irritable, and there is inability to concentrate 
 her mind, and she has headaches, marked weakness and general 
 debility. DIGESTION AND ABSORPTION are deranged, thus causing 
 MALNUTRITION. If a patient presents herself suffering with the 
 above symptoms and dates the trouble back to childbirth, lac- 
 eration should at once be suspected. 
 
 PHYSICAL SIGNS. By means of the finger in vaginal ex- 
 amination, the indentation or fissuring of the cervix can be dis- 
 tinctly outlined. The os is usually patulous on account of the 
 attending subinvolution. 
 
 The various Nabothian glands which open on the cervical 
 mucous membrane become inflamed. The DUCTS become FILLED 
 and LITTLE RETENTION cysts form, which are called NABOTHIAN 
 CYSTS from the name of the glands. At first they are soft, of 
 about the size of a small shot and when punctured discharge a 
 gelatinous fluid. Afterwards they become hardened and em- 
 beded in the cervix. After this takes place, they resemble on 
 palpation shot sunken in the substance of the cervix. They are 
 often quite extensive and are diagnostic of a condition of cystic
 
 330 DISEASES OF WOMEN. 
 
 degeneration of the cervix, which is the immediate result of the 
 vascular changes incident to laceration of the cervix. 
 
 The EVERTED CERVICAL MUCOSA can be felt as a roughened 
 surface. Various names have been applied to this condition of 
 the roughening and eversion of the mucous membrane, such as 
 erosion, granular erosion, excoriation and ulceration. Some- 
 times the lips are turned back so far, as in marked bilateral lac- 
 eration, that the indentation can not be felt; only the roughened 
 surface being recognized. To this has been given the name of 
 BELL-SHAPED CERVIX on account of the lower part of the cer- 
 vix being wider than the upper part. In certain cases the cer- 
 vical endometrium is partially everted. This is found most fre- 
 quently on the anterior lip and is the result of eversion from 
 laceration. The os is CRESCENT-SHAPED and the shorter lip is 
 thin. 
 
 If the case cannot be diagnosed definitely by digital examina- 
 tion a speculum should be introduced. By exposing the cervix 
 by means of this instrument, the granular surfaces, the flatten- 
 ed cervix, the hypertrophy of the lips and the radiating fissures 
 can be seen. If vulsella are now used to pull down or unroll the 
 everted lips, the degree of the tear can be definitely ascertained. 
 
 It is diagnosed from an endometritis with slight protrusion 
 of the endometrium, by the size of the cervix and the shape of 
 the os, as determined by inspection. From cancer it is diagnosed 
 by the absence of cancerous symptoms, and especially by the 
 absence of friability and tendency to hemorrhage on slight irri- 
 tation. 
 
 Prophylaxis. An osteopath SHOULD NOT PERMIT LACERATION 
 to take place unless a deformity or marked abnormality exists. 
 The best way to cure laceration is TO PREVENT it. This is done 
 by FIRST dilating the os uteri by inhibition of the clitoris; sec-
 
 LACERATION OF THE CERVIX. 331 
 
 OXD. not hastening labor by artificial means; THIRD, by not using 
 drugs or instruments; and FOURTH, by regulating and controlling 
 the rapidity of the birth of the child. 
 
 If dilatation is rapid, it is not best to let the head be forced 
 out of the uterus with a strong pain, but hold it back and deliver 
 between pains or at the latter part of it. Between pains I RIM 
 OUT THE os with one or more fingers by which symmetrical dilata- 
 tion can be secured. If one side of the cervix becomes very thin, 
 it tends to tear when a pain forces the head against it. To avoid 
 this force the head, when the pain is on, against the opposite 
 side, in other words, guide the passing of the fetus, especially 
 the head, out of the uterus, which, when carefully done will pre- 
 vent laceration. In a normal labor no blood should be lost prior 
 to the clots expelled immediately after the completion of the 
 second stage and with the placenta. The LEAST AMOUNT OF 
 BLOOD before the second stage is COMPLETED is INDICATIVE OF 
 A TEARING OF SOME part of the genital tract, usually the cervix. 
 Out of nearly one thousand cases delivered by Dr. C. E. Still and 
 myself, I know of but few cases in which we had complete care 
 of the case, that there w r ere lacerations, and they were abnormal 
 cases, in that the pelvis was deformed, the uterus diseased, the 
 fetus very large, or the fetus had to be delivered rapidly on ac- 
 count of the hemorrhage from a malposed placenta. 
 
 TREATMENT. The treatment should be directed to get 
 union and healing of the irritated and inflamed edges. If there 
 is in the parts, a chronic inflammation with degeneration, such as 
 is the case in erosion or ulceration, it is hard to get the edges to 
 unite: often the stitches making the condition worse. If the 
 parts are not badly inflamed, that is if the inflammation is not 
 chronic, union can be secured by an operation. This operation 
 is called trachelorraphy. In chronic cases, the surfaces are
 
 332 DISEASES OF WOMEN. 
 
 first denuded and then sutured. Rest of the part should follow 
 the operation until complete union has taken place. Coition 
 should be forbidden as long as there is any inflammation what- 
 ever, lest the condition be made worse by the congestion and irri- 
 tation of the parts. 
 
 If the case is a CHRONIC ONE, and the inflammation has re- 
 ceded, an operation will do little if any good, unless there has 
 been an excessive amount of fibrous material deposited. In 
 these kind of cases a "V" shaped plug is usually removed, 
 this lessening the hypertrophy and relieving the impingement 
 on the nerve terminals. I have seen large lacerations which 
 have spontaneously healed, which caused the patient no appar- 
 ent trouble. I doubt that scar tissue in the cervix causes any 
 trouble whatever. 
 
 Amputation of the cervix is resorted to in cases of deep stel- 
 late laceration. In some, the condition of the patient is better- 
 ed, in others made worse. The writer has seen several cases in 
 which the operation had been performed, in which the condition 
 was made a great deal worse as far as the uterus was concerned. 
 DYSMENORRHEA of a very bad type often follows. CYSTIC de- 
 generation with its softening of the uterus occurs in other cases. 
 In one case treated by the writer the cramps came on as many 
 as ten days before the flow and continued about two weeks at 
 each period. They were so strong that the patient was exhausted, 
 the menstrual period being a great deal more painful than par- 
 turition. This patient was entirely free from menstrual pain 
 prior to the operation, but pain appeared at the first menstrua- 
 tion after. On local examination there was found two openings 
 to the uterus; also a slight displacement. The pains could be 
 lessened a great deal by instrumental dilatation immediately 
 before the menstrual period.
 
 LACERATION OF THR CERVIX. 333 
 
 It is BEST to REPAIR the tear in the cervix as soon as there 
 is marked involution, and that is about the FIFTH OR SIXTH WEEK. 
 This prevents secondary inflammation and guards against can- 
 cerous growths. Some advocate an immediate operation, but 
 it is not indicated unless there is profuse hemorrhage. There 
 is difficulty in recognizing the extent of the injury, the cer- 
 vix being large and flabby, and thus it makes the operation un- 
 certain unless the uterus has regained to a certain extent, its 
 former size. The DANGERS OF INFECTION are increased by an 
 operation at this time unless strict antiseptic precautions are 
 taken. Such precautions are not always possible at private 
 homes at which most cases occur. 
 
 The cases that the osteopath will meet with are chronic ones, 
 since it is a very rare thing to have a laceration occur which is 
 deep enough to cause either local or reflex effects, if handled by 
 our osteopathic methods. If a patient were to come to you suf- 
 fering with leucorrhea, menstrual disorders, pain, reflex and local, 
 and an erosion and ulceration is found, the case should first be 
 treated for awhile before an operation is advised even if one 
 were needed. If the treatment does not relieve the inflammation 
 then an operation should be advised, whereby the two edges can 
 be approximated. 
 
 I have cured numbers of cases in which there were marked 
 lacerations. This can be done if there is not too much inflam- 
 mation or irritation to the parts, which prevents healing. The 
 treatment used is one directed to CONTROL THE PELVIC CIRCU- 
 LATION. Treatment applied over the lumbar and sacral re- 
 gions, causes increased vaso-motor tonicity. Manipulation over 
 the course of the abdominal and pelvic veins removes obstruc- 
 tions to the return flow of blood. By keeping the patient quiet, 
 and continuing the treatment for few weeks, a great many of
 
 334 DISEASES OF WOMEN. 
 
 the symptoms can be relieved. Stimulation of the nerve cen- 
 ters of the uterus, located in the lower lumbar region, produces 
 contraction of the uterine muscle fibers. This forces the venous 
 blood out of the uterus and results in lessening the size 
 of it. LESIONS along the lower lumbar and sacral regions some- 
 times prevent complete involution and increase the congestion 
 and inflammation which attend laceration. By correcting these 
 lesions, the congestion and inflammation are lessened, thereby 
 increasing the probability of a cure without an operation. 
 Although an operation is often indicated if the case is compara- 
 tively a recent one since it is a surgical condition, the treatment 
 will very materially help the healing of the parts, and should be 
 given. OSTEOPATHY is CERTAINLY QUITE AN ADJUNCT TO SUR- 
 GERY. If by the treatment the blood is kept circulating through 
 the uterus it lessens the pain and SHORTENS the length of 
 time of healing.
 
 EROSION" OF THE CERVIX. 335 
 
 EROSION OF THE CERVIX. 
 
 Erosion of the Cervix is a circular, irregular, roughened 
 patch surrounding the os, which is RAW in appearance. Some- 
 times there are granular patches with irregular outlines which 
 extend beyond the limits of the os externum. The pavement 
 epithelium has been partly or wholly destroyed and replaced by 
 newly formed cells, which are columnar in shape. New gland 
 tissue is formed which is secreting and resembles in structure 
 the cervical mucous membrane. This leads to abnormal secre- 
 tions such as leucorrhea. 
 
 The term ulceration has been applied to this condition, but 
 erosion is a better term, since very rarely there are actual ulcer- 
 ative changes. Ectropium or eversion of the mucous membrane, 
 is a term used to describe the condition when there is laceration, 
 but does not describe the secreting surface beyond the os externum. 
 
 CAUSES. In the young and the nulliparous woman, EX- 
 POSURE during menstruation is a common cause. Imprudent 
 exercise or over work at the menstrual period, produces a dis- 
 turbance of the uterine circulation. If this is persisted in month 
 after month, congestion or even inflammation will result. Let 
 us examine one of those eroded surfaces. It shows vascular 
 changes, for it is congested, and since papillae and granules of 
 different size are formed over the diseased area. To produce 
 this the circulation must be impaired, and in most cases this is 
 a venous rather than an arterial disturbance. Since venous 
 blood supports only the lower form of life, connective tissue and 
 hypertrophied epithelium are in abundance. 
 
 The causes of this congestion in nullipara, in addition to ex-
 
 336 DISEASES OF WOMEN. 
 
 posure during menstruation, are LESIONS deranging the nerve 
 supply. If this collection of the blood in the mucous membrane 
 lining the os becomes chronic, these erosive changes follow. Cer- 
 tain women are predisposed to chronic congestion of all the mu- 
 cous membranes. The writer recently treated a case of mem- 
 branous dysmenorrhea in which there was hemorrhage from nearly 
 all the mucous membranes during the menstrual period. There 
 was a small erosion of the cervix, and on this account the uterus 
 had been curetted, wdth little or no benefit. 
 
 In MULTIPARA, childbirth is the most common cause, es- 
 pecially if a laceration has taken place. This condition excites 
 congestion of the cervix and its lining membrane. There is a 
 hypersecretion and an irritating discharge. This discharge is 
 often strongly acid and irritating if it comes from the uterus. It 
 ERODES the tissues, mucous membrane and integument with 
 which it comes in contact, and the CERVIX ON INSPECTION RE- 
 SEMBLES A RAW PIECE OF FLESH. The local congestion around 
 the impaired area soon develops into a circumscribed inflamma- 
 tion. After it exists for awhile the characteristic roughened, 
 granular surface appears. The inflammation may extend up- 
 ward from a vaginitis, or downward from an endometritis. In 
 such cases, if not of specific origin, a bony lesion or uterine dis- 
 placement are the most important causes. 
 
 SYMPTOMS. The cervix being considered as a LARGE GLAND, 
 the congestion produces a pathological secretion which is called 
 leucorrhea. If there were an arterial congestion, there would 
 be a hypersecretion, but it would be normal as to quality, but 
 being a venous congestion the quality of the seretion is impaired 
 and the quantity increased. The normal secretion is clear and 
 viscid, resembling the white of an egg. If mucous corpuscles 
 are present it is an opaque white; if there are pus corpuscles it
 
 EROSION OF THE CERVIX. 337 
 
 becomes yellowish; if blood is present it becomes red in color. 
 
 PAIN as in all inflammatory conditions of the uterus, is pres- 
 ent, either localized or reflected to the back. It is increased on 
 walking or in conditions in which there is movement. Men- 
 strual disorders are present, principally menorrhagia and dys- 
 menorrhea. On account of the inflamed condition of the endo- 
 metrium and the character of the secretion, it being acid, steril- 
 ity frequently exists. 
 
 PHYSICAL SIGNS. On vaginal examination the cervix is 
 found to be SOFT and the os PATULOUS. The eroded and rough- 
 ened surfaces can usually be felt. By exposing the cervix with 
 a speculum, the raw, eroded surface can be seen. Frequently 
 an old laceration can be seen, which is the cause of the trouble. 
 An erosion bleeds readily when touched with the finger or an in- 
 strument. Discharge can be seen exuding from the part, or if 
 there is a co-existing endometritis it can be seen coming from 
 the uterine cavity. It is diagnosed from cancer by lack of odor, 
 absence of marked friability and the character of the hemorrhage. 
 The EROSION is LOCALIZED and does not produce constitutional 
 changes. 
 
 TREATMENT. The treatment resolves itself into a build- 
 ing up of the general condition and relieving the congestion of 
 the cervix. In nullipara it should be applied to the lesions found 
 which interfere with the pelvic circulation. If the uterus is 
 displaced, which is the case with a great many patients suffering 
 with erosion, it should be corrected in order to relieve the venous 
 congestion, otherwise local treatments will do very little good. 
 
 In MULTIPARA,' the treatment should be similar, but in ad- 
 dition, the laceration, if any exists, should be repaired if it does 
 not heal after the usual treatment is given. Local douches do 
 very little good. They may relieve the condition temporarily,
 
 338 DISEASES OF WOMEN. 
 
 but the after effect leaves them in a worse condition than when 
 they began. Sometimes applications of tannin and glycerine 
 are recommended, but they give only temporary relief. Bis- 
 muth is the best antiseptic to use if one is indicated. Others ap- 
 ply caustics to the eroded surface, but this seems to be rather a 
 cruel way of treating such a condition. Deep work over the 
 uterus, and the veins leading from it, with treatment applied to 
 the back to increase the vaso-motor tonicity, is usually sufficient 
 to at least relieve if not cure the erosion. The patient should be 
 kept as quiet as possible and coition should be prohibited.
 
 ULCERATION OF THE CERVIX. 339 
 
 ULCERATION OF THE CERVIX. 
 
 ULCERATION OF THE CERVIX is occasionally met with. 
 It is a condition of advanced erosion, that is, the blood has stag- 
 nated so long that ulcerative changes have set in. On examina- 
 tion with the speculum, the ulcerative process can be seen. 
 Venereal diseases, especially syphilis, should be thought of since 
 an ulcer is sometimes formed on the cervix as a result of the in- 
 fection. The discharge in ulceration would be of a yellowish 
 color, since pus from the ulcer is intermingled with it. In most 
 cases there is a constitutional disease such as tuberculosis, which 
 impairs the quality of the blood and prevents healing after lac- 
 eration. The treatment should be similar to that of erosion, 
 that is, the stagnated blood removed and fresh blood be put in its 
 place. In addition, measures should be adopted to build up the 
 general health by the proper kind of food and exercise. If the 
 ulceration is persistent and does not yield to the ordinary treat- 
 ment ^to the uterus, abdomen and spine, some antiseptic prepara- 
 tion should be used directly on the ulcer. Boracic acid or bis- 
 muth can be used advantageously.
 
 340 DISEASES OF WOMEN. 
 
 INFLAMMATION OF THE UTERUS. 
 
 The Uterus is the seat of a great many inflammatory changes 
 both acute and chronic. Various authors divide these inflamma- 
 tory conditions into many divisions and subdivisions, such as 
 acute and chronic metritis, both corporeal and cervical, acute and 
 chronic endometritis, and endocervicitis. For our purpose the 
 general division of inflammation of the uterus into metritis and 
 endometritis is sufficient. This division is only arbitrary, since I 
 doubt if there is ever a case of endometritis without it being 
 complicated with inflammation of the substance of the uterus or 
 metritis, or vice versa. Since both the endometrium and uterine 
 walls are supplied by the same nerves, blood vessels and lym- 
 phatics, consequently the same lesions, or other disturbing ele- 
 ments, affect both. Also the endometrium is in intimate rela- 
 tion with the muscle fibers of the uterine walls. 
 
 First, let us consider what is the condition in inflammation 
 of the uterus. It is an ATTEMPT or effort accompanied by red- 
 ness, heat, swelling and pain on the part of the ORGAN to counter- 
 act, excrete or destroy certain poisonous or obnoxious elements. 
 These poisonous elements either arise from within, or are intro- 
 duced from without. If introduced from without, the poison at 
 first stimulates for a short time the nerve terminals, but soon 
 produces a weakening, or paresis, of the vaso-motor nerves, and 
 the blood flow, both arterial and venous, is lessened in rapidity 
 or even entirely stopped; in other words, CONGESTION or a stasis 
 results. The blood then undergoes changes which are PECU- 
 LIAR TO INFLAMMATION, accompanied by exudations and de- 
 posits, and changes in the tissues supplied by the blood ves- 
 sels. Inflammation as a rule, most frequently attacks the en- 
 dometrium, which then is called endometritis. It soon invades
 
 INFLAMMATION OF THE UTERUS. 341 
 
 the neighboring substance and becomes a metritis. 
 
 The poisonous elements that arise from within are the re- 
 sult of a local stagnation of blood. This stagnation results from 
 DISPLACEMENTS of the uterus and bowels; DISEASE of the ADNEXA. 
 or it follows EXPOSURE of the body at a time when the uterus is 
 physiologically congested, as during the menstrual flow; also from 
 the various LESIONS affecting the vaso-motor centers which have 
 to do with controlling the amount of blood in the uterus. Some- 
 times there are constitutional diseases which are responsible for 
 the condition, but this is rare in comparision with other causes 
 which will be mentioned under the head of causes of inflamma- 
 tion of the uterus. 
 
 Pryor says "it is an accepted fact that pelvic disease in 
 women is increasing. This is due to three causes : The undoubt- 
 ed spread of gonorrhea; the very general dislike to childbearing 
 and the induction of abortion, and to unskilled intra-uterine treat- 
 ment by physicians." The writer agrees to the above state- 
 ment, and would add that the UNSKILLED TREATMENT of uterine 
 diseases in general is a very important factor in the production 
 and increase of pelvic diseases in women. 
 
 THE BLOOD SUPPLY of the uterus is very abundant. The 
 VEINS are large and traverse the uterus in every direction. A 
 PECULIARITY of the blood supply is the DISPROPORTION between 
 the size of the arteries and veins, the latter being the larger. 
 Mayrhofer says "When the vessels of the uterus are injected, the 
 veins and arteries with different colored injection, one is struck 
 by the great preponderance of veins over arteries." Their walls 
 are very thin so that a very slight change of pressure readily af- 
 fects the blood stream. The blood is collected by the uterine and 
 ovarian veins and returned to the inferior vena cava, thence to 
 the heart. The UTERINE VEINS accompany the arteries, that is,
 
 342 risEASES OF WOMEN. 
 
 their course at first lies between the layers of the broad ligaments, 
 after which they empty into the internal iliac veins, thence the 
 blood is carried by the inferior vena cava to the heart. The 
 OVARIAN VEINS, like the arteries, are long and slender, hence the 
 greater liability of compression. The left empties into the renal, 
 while the right empties directly into the inferior vena cava. 
 
 Respiration affects the uterine blood pressure as well as the 
 position of the uterus. This has been proven in different ways. 
 By placing the finger against the cervix when the patient is strain- 
 ing as in coughing, the change in position and consistency can 
 be readily noted. The analogous veins in the male, the sper- 
 matic plexus, increase in size when the intra-abdominal pressure 
 is increased. The author has experimented on cases of vari- 
 cocele. The distention of the veins could be markedly increased 
 by having the patient hold his breath and straining as if at stool. 
 The veins could also be enlarged by the patient lifting or, in fact, 
 doing anything which caused an increase in the intra-abdom- 
 inal pressure. I recently had a case in which the patient, a young 
 lady, was groaning and breathing irregularly, that is, she was 
 holding her breath as long as she could, then expelling it with a 
 groan. By keeping the finger on the cervix it was ascertained 
 that the pulsation of the blood vessels varied with the respira- 
 tion. The movements of the uterus also varied, SUDDEN IN- 
 SPIRATION DRAWING IT UPWARD, while holding the breath forced 
 it DOWNWARD. By placing the patient in the genu-pectoral posi- 
 tion and admitting air into the vagina and causing the patient to 
 breathe irregularly and forcibly, the air was drawn in with inspira- 
 tion and forced out with expiration, accompanied by the pecu- 
 liar sound of escaping air. This goes to prove the effect on the 
 position of the uterus in labored respiration and how easy it is to 
 produce a congestion of it, which is a preliminary step to in-
 
 INFLAMMATION OF THE LTERUS. 343 
 
 flammation of the same. Congestion can be produced by vaso- 
 motor disturbances. A lesion which inhibits and shuts off the 
 nerve force intended for the blood vessels causes dilatation of these 
 vessels. 
 
 PARTS INFLAMED. The part most COMMONLY INFLAMED 
 is the endometrium. It is composed of lymphatics, blood ves- 
 sels, nerves, glands and the ciliated columnar epithelium which 
 lines the cavity of the uterus. The walls are also frequently 
 inflamed, but usually secondarily to the inflammation of the 
 lining. They are composed of a mucous layer, muscular layers 
 and a peritoneal layer. The first is called the endometrium, the 
 second the myometrium, and the peritoneal covering, the peri- 
 metrium. Between these different layers are connective tissue, 
 glands, etc. These glands form a large part of the substance of 
 the uterus. Inflammation of the substance of the uterus, which 
 is called metritis, affects these glands, causing morbid secretions. 
 Inflammation of the endometrium is called endometritis ; of the 
 perimetrium, perimetritis or local peritonitis. 
 
 VARIETIES OF INFLAMMATION. The KIND of inflamma- 
 tion is named from its intensity, rapidity or according to the part 
 of the uterus affected. The inflammation may be acute or chronic 
 simple, catarrhal or parenchymatous, this classification being 
 called the pathological. The classification into metritis, cer- 
 vicitis, endocervicitis, endometritis perimetritis, parametritis 
 and peritonitis, is called the anatomical classification. 
 
 GENERAL CAUSES. The GENERAL CAUSES of inflamma- 
 tion are included in two general divisions. FIRST, traumatism, 
 or where the poison is introduced from without; or SECOND, con- 
 gestion, which is the result of obstruction or vaso-motor paresis. 
 The first includes all INJURIES to the endometrium, cervix and 
 uterine body whether from parturition, use of instruments or
 
 344 DISEASES OF WOMEN. 
 
 drugs. SPECIFIC INFLAMMATION of venereal origin is also in- 
 cluded under this head. The second includes misplacements, 
 bony lesions, tumors, both of the uterus and the neighboring 
 structures, subin volution, exposure, etc.
 
 ENDOMETRITIS. 345 
 
 EXDOMETRITIS. 
 
 The ENDOMETRIUM is not only a mucous membrane but is also 
 a part of the great lymphatic system. This being true, certain 
 of the general or systemic diseases affect it. In tuberculosis it 
 becomes pale and anemic; in gout and malaria it congests, 
 hence an increased menstrual flow. Its function then explains 
 the frequency of the uterine type of leucorrhea. 
 
 PATHOLOGY. In considering the pathology of en do met ri- 
 tis the component parts of the endometrium must be consider- 
 ed, and following this, the changes which each undergoes. The 
 endometrium is composed of glands, arteries, veins, lymphatics, 
 columnar and ciliated epithelium. The blood vessels are en- 
 gorged and soon the entire endometrium, and even the walls of 
 the uterus, becomes hyperemic. This is so marked in some 
 cases that a slight hemorrhage takes place when the uterus is 
 irritated, as in "local examination or sexual intercourse. The 
 epithelium, the cells of which being thickened and prolif- 
 erated, becomes loosened, disintegrated and expelled with the 
 leucorrheal discharge. The secretions, in typical cases, become 
 muco-purulent ; this being the result of glandular disturbances. 
 The mucous membrane is often several times as thick as the nor- 
 mal and becomes spongy, soft and easily removed. 
 
 CAUSES. Endometritis Is most easily produced by an in- 
 strumental intra-uterine treatment, the SOUND being the instru- 
 ment most often used. If care is not taken the delicate mucosa 
 lining the uterine cavity will be torn or injured by the pressure 
 exerted in replacing a displaced uterus. UTERINE DILATORS or 
 tents, that are sometimes used, are also liable to and usually do,
 
 346 DISEASES OF WOMEN. 
 
 injure the tender endometrium. This leads to congestion, which 
 is followed, in most instances, by some degree of inflammation. 
 The uterine cavity is one that should not be irritated or per- 
 mitted to be rilled with air. This form of inflammation pro- 
 duced by the above is usually acute. 
 
 PESSARIES which have been worn for some time without re- 
 moval, irritate and congest the vagina and cervix, and inflamma- 
 tion follows. SPECIFIC VAGINITIS or gonorrhea travels upward 
 from the vagina and sets up an inflammation of the endometrium 
 Sometimes it travels up the Fallopian tubes into the ovaries 
 and peritoneal cavity. This is a cause of constant ill health, 
 chronic local peritonitis and sterility. Infection may come from 
 other sources such as the use of unclean instruments or dirty 
 hands. Certain drugs tend to produce inflammation of the 
 uterus. 
 
 Peculiar conditions of the blood state tend to produce con- 
 gestion of the mucous membrane. This not only affects the endo- 
 metrium, but the various other mucous membranes of the body. 
 This is often found in_the exanthemata, also in hemophilia or 
 bleeders disease. 
 
 EXPOSURE to cold or GETTING WET during the menstrual 
 flow, is a common cause of endometritis. Mental anxiety or 
 any sudden emotion which stops the menstural flow frequently 
 produces inflammation. I have seen a great many cases of in- 
 flammation of the uterus which started from over-work or ex- 
 posure at the menstrual period. Such patients are tender over 
 the lower part of the abdomen and have chronic menstrual dis- 
 orders. This menstrual discharge, which should have been 
 thrown off, collects in the uterine cavity on account of the con- 
 traction of the cervix which occludes the os. It is partly ab- 
 sorbed and continues to be a source of constant irritation and 
 congestion.
 
 ENDOMETRITIS. 347 
 
 PARTURITION, if accompanied by laceration or bruising of 
 the cervix, is a cause of inflammation of the uterus, and especial- 
 ly of endometritis in multipara. The inflammation soon becomes 
 chronic and is the cause of many complications. 
 
 If there are too frequent pregnancies or abortions the uterus 
 will be found enlarged and inflamed. This is called subinvolu- 
 tion. The inflammation will not be confined to the endometrium 
 but invades the walls. INDUCED ABORTION and frequent coitus 
 are other causes which may first set up a congestion, then an in- 
 flammation of the lining membrane of the uterine cavity. In 
 either case the os becomes and remains patulous. 
 
 Displacements produce inflammation by first exciting con- 
 gestion. On account of the obstruction to the circulation pro- 
 duced by the twisting of the broad ligaments or by direct pressure 
 on the vessels, the blood undergoes changes which result in the 
 formation of toxic elements. If the displacement has become 
 chronic, there is but little inflammation, but if it is an acute or 
 recent one, there is usually acute inflammation, not only of the 
 uterus and its lining but of the neighboring structures. 
 
 MEDICATED pencils introduced into the os, excite inflamma- 
 tion of the endometrium whenever used. Caustics and the vari- 
 ous astringent applications, if used very much, have a similar 
 effect on the uterus. They at first stimulate the vaso-motor 
 nerves, but relaxation and dilatation soon follow after the first 
 effects have worn off. 
 
 Passive congestion as the result of some of the above causes, 
 or of a mechanical obstruction, is the most common forerunner 
 and cause of chronic endometritis. 
 
 LESIONS. The most COMMON and PRONOUNCED BONY LE- 
 SION is the backward slip of the innominate bones. Both bones,
 
 348 DISEASES OF WOMEN. 
 
 or only one, may be slipped backward, thus producing a twist in 
 the entire pelvis. This kind of lesion, more than any other, 
 seems to affect the uterine circulation. The sacrum may be 
 tilted, its most common displacement being a forward rotation of 
 the upper part and a posterior displacement of the lower part. 
 The lumbar vertebrae may be displaced, or a RIGID condition of 
 that part of the spine may exist, or a posterior CURVE be found. 
 
 If due to exposure the muscles along the lower part of the 
 spinal column are found to be very much contractured. This is 
 frequently the beginning of the bony lesions. The tension ex- 
 erted by a contracted muscle is considerably more than one 
 would at first suppose. This finally results is a slight bony dis- 
 placement, that is, the bone is slowly pulled out of line. When 
 once it is out, it becomes in most cases a chronic condition, affect- 
 ing the uterine circulation and probably causing a chronic form 
 of metritis or, endometritis. 
 
 To the osteopath THESE LESIONS are the most important of 
 the causes of endometritis. With these bony lesions existing, 
 exciting causes readily act. Without correcting these lesions 
 permanent cures cannot be made, although temporary relief 
 may be given. Cases of membranous dysmenorrhea, which is 
 only one of the many forms of this inflammation, can be cured by 
 osteopathic methods even after other methods have failed. This 
 has been demonstrated a great, many times in our own practice. 
 In such cases a bony lesion was found, the subluxated innominate 
 being the most common, and after correction the symptoms dis- 
 appeared. 
 
 SYMPTOMS. The symptoms of an endometritis depend 
 upon the degree of inflammation. The acute form is accom- 
 panied by the usual indication of inflammation, such as heat, 
 redness, swelling, pain and perversion of function. The ABDO-
 
 ENDOMETRITIS. 349 
 
 MEN is tense, tender and in most cases tympanitic. The neigh- 
 boring organs are affected, menstrual function is deranged, and 
 an acute pain and tenderness exists in the pelvic region. There 
 will be symptoms of peritonitis, especially in cases produced by 
 exposure during the menstrual flow. 
 
 The MOST IMPORTANT SYMPTOM of chronic endometritis is 
 PAINFUL MENSTRUATION. The uterus contracts to expel the 
 menstrual flow. If the endometrium is raw and inflamed, and 
 it is in endometritis, it is like clenching the hand when the palm 
 is raw and eroded, both of which result in severe pain, and the 
 greater the contraction the worse the pain. 
 
 Again, the IRRITATED ENDOMETRIUM is conducive to uterine 
 contraction. The introduction of any instrument or anything 
 into the uterine cavity produces contraction of the uterus, and 
 especially so if the endometrium is in a state of irritation, the 
 uterus responding to a lesser stimulus than it does when normal. 
 On account of the above mentioned conditions any shock, ex- 
 posure, injury or lesion will more readily cause uterine contrac- 
 tion and dysmenorrhea. This explains POST-MENSTRUAL and 
 INTER-MENSTRUAL pain, that is, a lesion is present which, coupled 
 with some exciting cause, results in increased peristalsis of the 
 uterus. 
 
 The AMOUNT OF MENSTRUAL PAIN depends upon the degree 
 of inflammation. If the blood has been retained in the uterus 
 even for a short time, it becomes clotted and then the process of 
 expulsion is similar to that of labor. In fact, if there is clotted 
 blood discharged at the menstrual period it indicates inflammation 
 of the endometrium and is one of the best symptoms of the same. 
 
 Nearly all uterine pains at the menstrual period, come from 
 inflammation of the endometrium. FLEXION rarely produces 
 dysmenorrhea unless accompanied by inflammation. REFLEX
 
 350 DISEASES OF WOMEN*. 
 
 troubles at that time are rare unless there is an endometritis. 
 
 MEMBRANOUS DYSMENORRHEA is a very striking symptom 
 or example of endometritis. The entire lining of the cavity of 
 the uterus is loosened and cast off EN MASSE, this loosening of 
 the endometrium being the result of changes dependent on endo- 
 metritis. The pain is due partly to the inflammation and partly 
 to the presence of the membrane, both of which are likely to set 
 up an extreme contraction of the uterus in its efforts to expel or 
 overcome the foreign body or the irritation. 
 
 In GONORRHEAL ENDOMETRITIS, the onset is sudden, with 
 fever, uterine cramps and general pelvic pain, soon followed by a 
 discharge which rapidly becomes purulent. The inflammatory 
 process soon extends to the Fallopian tubes, ovaries and pelvic 
 peritoneum. The vulva and vagina show signs of inflammation. 
 The MEATUS has a dark red appearance; the uterus is very ten- 
 der and the gentlest manipulation causes marked pain. It en- 
 larges and the connective tissues about it thicken. 
 
 The LYMPHATIC GLANDS increase in size and become very 
 tender. The OVARIAN tenderness increases while the endome- 
 tritis becomes less severe. A CHRONIC DISCHARGE is establish- 
 ed, which increases in amount whenever uterine congestion is 
 increased, as at the menstrual period. The discharge contains 
 pus and is sometimes very irritating. 
 
 As a result of the congested mucous membrane, the SECRE- 
 TIONS become abnormal. Instead of the uterine secretion HE- 
 ING WATERY in character it becomes whitish, MILKY or BLOOD 
 tinged. In other cases it is purulent on account of its retention 
 and accumulation in the uterine cavity. The discharge is fre- 
 quently strongly aci 1 in character and sets up a pruritus. BACK- 
 ACHES and various other reflex aches are very common. Endo- 
 metritis is the MOST COMMON CAUSE of reflex pains or aches.
 
 ENDOMETRITIS. 351 
 
 The congested condition which accompanies the inflamma- 
 tion increases the weight of the uterus, thus producing pressure 
 on some parts and traction on other parts. This congestion often 
 leads to hemorrhage in the form of a menorrhagia, or even a 
 metro rrhagia. The effects depend on the amount and quality 
 of blood lost. Anemia, indigestion and general weakness most 
 frequently follow. 
 
 The DISTURBANCE OF THE UTERINE CIRCULATION affects 'the 
 
 PELVIC NERVOUS system. The VARIOUS REFLEXES are the re- 
 sult. The limbs are heavy and the small of the back weak. If 
 a patient were to come to you suffering with a weak back, that is 
 if she complained of an ache, or an acute pain, suspect an inflam- 
 mation of the uterus, either an endometritis or a metritis, the 
 former being the more common. This backache as men- 
 tioned above may be the result of a lesion, sexual excesses, 
 laceration or displacement. The DEGREE and character of the 
 pain in uterine displacements depend more on the amount of 
 inflammation, that is endometritis and metritis, THAN ALL OTHER 
 THINGS COMBINED. A uterus free from inflammation is in most 
 cases, a fairly normal one regardless of its position, and if disease 
 exists one should look elsewhere than in the uterus for the cause. 
 
 When the UTERUS or. part of it is INFLAMED the digestive 
 tract is usually weakened. Digestion is impaired and appetite 
 lost. Frontal headaches are sometimes found which are reflex 
 from the stomach. Sometimes nausea and vomiting exist, which 
 may lead one to suspect pregnancy. I recently had a case of 
 slight endometritis complicated by morning nausea and vomit- 
 ing, which was mistaken for pregnancy. Local examination 
 cleared up the diagnosis. 
 
 STERILITY is almost a constant symptom. The acid leu- 
 corrheal secretions from the uterus conteract and kill the sper-
 
 352 DISEASES OF WOMEN. 
 
 matozoa. Sometimes impregnation does take place, but if it 
 does the woman seldom carries to term. The endometrium be- 
 ing congested and inflamed furnishes an imperfect NIDUS' for at- 
 tachment of the impregnated ovum. In some cases the fetus 
 is carried to term, but this is the exception to the rule. To make 
 a resume, the symptoms are dysmenorrhea, leucorrhea, reflex 
 aches, digestive disturbances, nervous changes such as hysteria 
 and usually sterility. 
 
 PHYSICAL SIGNS. Tenderness is elicited on pressure over 
 the lower part of the abdomen. This is one of the BEST OBJEC- 
 TIVE indications of an inflamed uterus, whether metritis or endo- 
 metritis. In such cases care should be taken not to mistake 
 CYSTITIS, for an inflammation of the uterus. 
 
 On local examination the CERVIX is found to be LARGE AND 
 SOFT, while the os is patulous. Sometimes the endometrium is 
 everted and can be felt. On examination with the speculum, 
 the inflamed surface can be seen if it involves the cervical endo- 
 metrium or if the case is not one of too long standing. The cer- 
 vical endometrium is raw looking, and the leucorrheal discharges 
 are seen emanating from the external os. The least movement 
 of, or pressure on the uterus, produces pain. There is painful 
 coition or dyspareunia if the inflammation is acute. If the sound 
 is introduced it becomes tinged with blood. It excites pain, 
 sometimes spasms, in which cases it should not be used. PRES- 
 SURE ON THE UTERUS through the fornices, per rectum or through 
 the abdominal wall, CAUSES PAIN. 
 
 DIAGNOSIS. In laceration of the cervix there are similar 
 subjective symptoms, but the physical examination reveals radiat- 
 ing fissures by which it is definitely diagnosed. It is DIAGNOSED 
 from cancer by absence of the usual signs of cancer, such as fri- 
 ability, sudden hemorrhage, fetid odor and watery discharge
 
 ENDOMETRITIS. 353 
 
 If in doubt, a microscopical examination should be made. There 
 are various conditions, such as granular erosion, ulceration and 
 the above mentioned diseases, which are accompanied by an endo- 
 metritis but have in addition their own peculiar symptoms. 
 
 PROGNOSIS. The prognosis, as in other inflammatory dis- 
 eases, depends upon the length of standing, causes, and the in- 
 dividual case, each one being different. In most cases it is good. 
 If venereal disease is present producing it, the prognosis is not 
 so good, since the disease, when once in the uterus or Fallopian 
 tubes, is very hard to eradicate. If due to a laceration and the 
 patient otherwise in good health, it is favorable. If the patient 
 is pale, anemic, the blood thin, and there is much weakness, the 
 prognosis, as to a cure is unfavorable, but for relief it is favor- 
 able. Under osteopathic treatment the prognosis is a great deal 
 more favorable than under any other, and it is the exception to 
 meet with a case that cannot at least be helped if not entirely 
 cured. Cases have been cured at the Infirmary at Kirks ville, 
 in which the inflammation was so marked that the entire endo- 
 metrium was throw r n off EN MASSE every few days, that is, just 
 as often as it was formed. 
 
 TREATMENT. The treatment of endometritis depends on 
 the cause producing it and the stage of inflammation. The ob- 
 ject to be attained is to relieve the congestion and to flush the 
 affected parts with pure blood. If a BONY LESION is found it 
 should be corrected as soon as possible, since a cure depends on 
 it. If it is ascertained that the cause is a displacement of the 
 uterus it should also be corrected, for the uterus will REMAIN 
 CONGESTED almost as long as it is malposed. If a laceration is 
 the cause, treatment should be directed to it to get union of the 
 two edges, or at least to remove the congestion. 
 
 The method most in vogue among physicians is curettage 
 
 23
 
 354 DISEASES OF WOMEN. 
 
 of the uterus. A dull or sharp instrument is introduced into the 
 cavity and the endometrium scraped away. It seems to me like 
 a barbarous method by which to torture a patient, and I have 
 the first case to see in which any permanent good resulted. Pa- 
 tient after patient has come to me for treatment for this disease, 
 that has had the operation performed one or more times. The 
 THEORY is that a new endometrium which is healthy will be 
 formed. IF THE NOURISHMENT WERE SHUT OFF FROM THE OLD 
 
 ENDOMETRIUM SO THAT THERE WAS CONGESTION AND INFLAMMA- 
 TION or DISTURBANCE IN NUTRITION, how could a healthy endo- 
 metrium be formed without first correcting the primary cause of 
 the trouble. It is treating the effect and leaving the cause alone. 
 Suppose a bony lesion, and by the way it is the most important 
 and common cause found, is producing the trouble; the uterus 
 might be curetted every month until the patient reaches the 
 menopause, but still the cause exists and the endometrium will 
 be diseased. Nostrom in speaking of curettage in endometri- 
 tis says: "I wonder how a procedure like this can have any in- 
 fluence on the inflammation of the uterine parenchyma, which 
 always co-exists to a greater or lesser degree with the endome- 
 tritis, when the latter has been of long standing. It appears to 
 me as if, when the mucous membrane is regenerated and connec- 
 tion between the endometrium and parenchyma is re-establish- 
 ed, the previous morbid symptoms would easily return, since they 
 have the same blood, lymphatic and nerve supply. This is just 
 what frequently happens and I attribute to this the frequent re- 
 lapses. I have seen one, two and even three relapses follow 
 curettage done by the most skillful gynecologists." 
 
 He further says: "Besides, to pretend to cure cervical 
 catarrh by curettage seems to me to be an illusion which the most 
 primitive anatomical knowledge will be sufficient to destroy."
 
 ENDOMETRITIS. 3o5 
 
 This Swedish author certainly voices the sentiment of most os- 
 teopaths on the above subject. Diseases must be treated from 
 the anatomical standpoint if a cure is expected. Treatment ap- 
 plied to an effect, and the use of a curette in endometritis is one, 
 will not remove the cause. 
 
 This bony lesion, usually a slipped innominate, shuts off part 
 of the nerve force which should go to the uterus. The circula- 
 tion is slowed and degenerative changes take place in the blood. 
 By the STIMULATION which results from a correction of these 
 lesions, both bony and muscular, the BLOOD PRESSURE is RAISED 
 and the OLD STAGNATED BLOOD FORCED OUT and replaced by new. 
 This is the object we want to attain. 
 
 Again, manipulate over the abdomen to lift up the intes- 
 tines, raise the diaphragm and remove the pressure from the 
 veins; this tends to relieve the congestion accompanying the en- 
 dometritis. Since endometritis is preceded by congestion, in 
 most cases the above becomes a VERY IMPORTANT TREATMENT. 
 Rest should be required and the patient not allowed to remain 
 long on her feet. 
 
 PROPHYLACTIC treatment should be given in cases of repeated 
 endometritis. The patient should guard against exposure and 
 excitement during the menstrual flow. Hot vaginal douches are 
 commonly advocated but I think they are of little use either as a 
 curative or prophylactic measure. 
 
 Recently the writer treated a case of chronic endometritis 
 coupled with membranous dysmenorrhea, in which a promi- 
 nent physician had advised a daily irrigation of the vagina in 
 which forty gallons of hot water were used at a sitting. This 
 was repeated daily for over a month. The patient survived and 
 the inflammation was partly relieved but the pelvic floor and 
 vaginal walls were greatly weakened. The mucous membrane
 
 356 DISEASES OF WOMEN. 
 
 seemed to be "washed out" and it took several months' treat- 
 ment to restore tone and normal secretion. Various medicated 
 preparations are advised, but they usually irritate instead of 
 alleviate. 
 
 In the gonorrheal type of endometritis little can be accom- 
 plished by antiseptic douches. This form of endometritis is very 
 hard to cure; in fact, it is regarded by most physicians as prac- 
 tically incurable. From an osteopathic view point, the same 
 kind of a treatment is given in this as in the other types of uterine 
 inflammation, that is, one directed to restoring normal circula- 
 tion through the uterus. This is ACCOMPLISHED in many cases 
 by correcting lesions, whether bony, muscular or visceral. In 
 other words, PERFECT ADJUSTMENT is attempted which, if secured, 
 will result in the cure of any disease unless death of too great 
 amount of tissue has taken place. IN AN ADJUSTED BODY THE 
 LLOOD is PURE, hence GERMICIDAL, and as a result, the gonococci 
 in the uterine cavity will be destroyed, if they come in contact 
 with it.
 
 METRITIS. 357 
 
 METRITIS. 
 
 Metritis is an inflammation of the parenchyma of the 
 uterus. It is usually found associated with endometritis, 
 sometimes as a cause, but more frequently as a result. It is also 
 found in connection with ovarian troubles and other pelvic in- 
 flammatory conditions. PERIMETRITIS is frequently found as 
 a complication, the patient complaining of tenderness and pain 
 over the lower part of the abdominal wall. Adhesions, joining 
 the uterus to some neighboring structure, are present as a result 
 of the exudate. 
 
 CAUSES. INFLAMMATION of the UTERINE walls is caused 
 by the same factors that enter into the causation of inflammation 
 of the endometrium, on account of the relation of the endome- 
 trium to the walls of the uterus. METRITIS ALWAYS COMPLI- 
 CATES ENDOMETRITIS, and in many cases the latter is the primary 
 inflammation of the uterus. It occurs more frequently as a se- 
 quel to parturition than from any other cause. While the uterus 
 is enlarged, it is congested and is subject to displacement and 
 injuries. Some writers describe subinvolution as a form of 
 chronic metritis. It is present in subinvolution. possibly as an 
 effect, not as a cause. Any CAUSE which INCREASES the CON- 
 GESTION of the uterus WILL PRODUCE INFLAMMATION of its sub- 
 stance. 
 
 The bony lesions are the most important causes of this form 
 of uterine disease. These lesions are commonly present in the 
 lumbar region; also the innominata are often found displaced. 
 The VASO-MOTOR centers for the uterus, also the CENTERS for the 
 TONE of the uterine muscle fibers, are affected by these lesions.
 
 358 DISEASE'S OF WOMEN. 
 
 Congestion of the uterus follows a disturbance of these vaso- 
 motor centers since the usual effect of the lesion on the center, 
 is that of inhibition. In chronic cases relaxation follows disturb- 
 ance of the center for tone of muscles. CRAMPING of the uterus 
 usually occurs as an immediate or primary effect. Since a cer- 
 tain amount of uterine contraction or tone is necessary to a nor- 
 mal uterine circulation, a vascular effect is produced by a dis- 
 turbance of the center for tone. ENLARGEMENT, with venous 
 engorgement, follows these disturbances which lead to chronic 
 metritis. 
 
 If the patient has led a life involving standing on the feet 
 a great deal of the time, the sacrum (lower part) is thrown back- 
 ward since the weight of the body is supported by the upper part 
 of the sacrum. If she leads a sedentary life and is not on her 
 feet very much, or there has been no jarring or straining of the 
 pelvis while in the erect posture, the lower part of the sacrum 
 may be thrown forward; but this is rare in comparison with the 
 other forms of displacement. If there is a kyphosis of the lum- 
 bar vertebrae the upper part of the sacrum will be drawn, or 
 rather forced, backward for compensation. SEDENTARY OCCUPA- 
 TIONS TEND TO PRODUCE A POSTERIOR LUMBAR CURVE WHICH IS FOL- 
 LOWED BY A STRAIGHT SACRUM. Displacements of the sacrum af- 
 fect the different muscles attached to these bones, especially the 
 quadratus lumborum, thus producing traction on the twelfth rib 
 
 and TENDERNESS IN THE SMALL OF THE BACK. 
 
 The various CAUSES MENTIONED UNDER ENDOMETRITIS will 
 also prdouce this condition, since both metritis and endo me- 
 tritis follow any condition resulting in uterine congestion. Ex- 
 posure during menstruation, injury, childbirth, constipation, 
 enteroptosis, strain of the back, displacement of the uterus, ab- 
 dominal and pelvic growths, infection, stem pessaries, intra-
 
 METRITIS. 359 
 
 uterine medication, excessive venery and the various devices 
 used to prevent pregnancy, and the BONY LESIONS mentioned 
 above are the most common causes. 
 
 A great many of these exciting causes depend upon the pre- 
 disposing weakness produced by these bony lesions. The most 
 important of these causes, judging from my own practice, are 
 exposure during menstruation and acute uterine displacement. 
 If the patient becomes chilled during the menstrual period, the 
 flow may be lessened or stopped; the uterus increases in size, fill- 
 ing the true pelvic cavity; fever follows and PERITONITIS of vary- 
 ing degrees is present in all cases. The uterus was physiologically 
 congested, the retention or lessening of the flow changing it to a 
 pathological congestion, which always PRECEDES INFLAMMATION. 
 
 A sudden prolapsus produces a similar effect ; first the conges- 
 tion, then swelling or enlargement of the uterus followed by in- 
 flammation. 
 
 These causes, however, are not always active unless there 
 are predisposing conditions which weaken the pelvic organs. 
 These predisposing causes are lesions, enteroptosis from stand- 
 ing, and subin volution from improper care at or just after labor. 
 
 In very chronic cases of metritis, after the acute symptoms 
 such as peritonitis, fever and acute congestion have diminished 
 or disappeared, the uterus becomes hardened or sclerosed; there 
 is an increase in the amount of connective tissue between the mus- 
 cle fibers; a thickening of the coats of the vessels, especially the 
 arteries; and UTERUS BECOMES ALMOST AS HARD AS CARTILAGE. 
 This is the result of inflammation, it terminating in such cases 
 in formation of scar tisue. 
 
 SYMPTOMS. In ACUTE METRITIS there may be a rigor, 
 fever, a distended, swollen condition of the abdomen with SHARP 
 pain and tenderness. On account of it affecting the peritoneum,
 
 360 DISEASES OF WOMEN. 
 
 the symptoms of peritonitis are present. The PRESSURE pains 
 are very severe; the BACKACHE is ALMOST UNBEARABLE; TENES- 
 MUS of the rectum with HEMORRHOIDS occurs in most cases; the 
 UTERUS ITSELF ACHES as does an edematous leg or testicle, on 
 account of the varicose condition of its veins; there is PERSIST- 
 ENT PELVIC pain with EXTREME ABDOMINAL TENDERNESS, this 
 being most marked in the iliac fossae; and the secretions are in- 
 creased and are of a VERY FOUL ODOR. 
 
 In chronic cases, menstruation is affected, usually painful 
 and increased in amount and the menstrual discharge clotted. 
 SECRETIONS are deranged, leucorrhea being usually present. 
 There is a constant SENSE OF WEIGHT, dragging SENSATION OF 
 the limbs, CHRONIC backache and HEADACHE. HYSTERIA in its 
 various forms may be present. FUNCTIONAL heart troubles are 
 common, the patient FAINTING on the slightest provocation. 
 NERVOUS DYSPEPSIA exists, and, in short, nearly all the reflexes 
 depending on inflammation of the uterus. A DISPLACED UTERUS 
 causes the GREATEST TROUBLE when congestion and inflamma- 
 tion accompany it. I have relieved various reflex pains and 
 aches supposed to have been due to a displacement, by partial- 
 ly relieving the inflammation and not correcting the displaced 
 uterus. It is best to correct the displacement if it can be done, 
 but in a great many cases it can not be done and you will have to 
 depend for relief of the symptoms upon the treatment to relieve 
 the congestion. Of course all the inflammation and congestion 
 in every case can not be removed while the uterus is still dis- 
 placed, but a large per cent, can, and this gives wonderful relief. 
 
 A great many women have displacements which give them 
 little or no trouble because there is no congestion or inflammation 
 attending them. As mentioned above, the AMOUNT OF PAIN, as 
 well as the number and intensity of the reflexes, is determined
 
 METRITIS. 361 
 
 by the character and degree of the pelvic inflammation. As 
 stated before, a UTERUS FREE FROM INFLAMMATION, that is, one 
 not tender on palpation, is about as normal as it is possible for 
 it to be, regardless of its position. 
 
 Metritis then, is the MOST IMPORTANT of uterine affections 
 and merits most attention. The most important sign in the 
 diagnosis of metritis is, the tenderness of the uterus as elicited by 
 abdominal and vaginal palpation. Pressure just above the 
 symphysis pubis, causes an acute or dull pain, it depending on 
 the amount and degree of inflammation of the uterus. As in endo- 
 metritis, cystitis should be kept in mind since pain is produced 
 on pressure just above the symphysis, if it is present. 
 
 On vaginal examination the os is found patulous, the cervix 
 soft and enlarged. In cervical metritis, digital examination re- 
 veals a SOFTENED area JUST INTERNAL TO an APPARENTLY CAR- 
 TILAGINOUS rim, which condition is possibly due to cystic degen- 
 eration. Sometimes there is a SOFT VELVETY COVERING on this 
 hardened rim, and shot-like bodies, as in laceration, are found 
 embedded in the cervix. These bodies can be seen on examination 
 with the speculum and give the cervix a wart-like appearance. 
 
 If the case is chronic, the vaginal walls are soft and weak. 
 A slimy discharge that is ,a vaginal leucorrhea is present, cover- 
 ing them. 
 
 On bimanual examination the entire uterus is found en- 
 larged and tender. Sometimes this examination can not be 
 made on account of the pain it causes. The uterus is usually 
 RETROVERTED or retroflexed, more frequently a mild form of the 
 latter. The corpus, weakened by inflammation, allows the fun- 
 dus to be forced either forward or backward according to the 
 forces acting upon it, since it is the support of the fundus. STER- 
 ILITY is a result, if the condition has existed for some time.
 
 362 DISEASES OF WOMEN. 
 
 PROGNOSIS. The prognosis is favorable in most cases. 
 Upon the relieving or cure of this condition DEPENDS THE CURE 
 of most cases of dysmenorrhea, reflex troubles, backaches, uterine 
 form of leucorrhea and the various local pelvic pains that are so 
 common in the female. If the condition is very chronic, do not 
 promise the patient a cure in a given length of time. If the 
 back is RIGID, and the bony displacements fixed and immovable, 
 it will take time to restore them to the normal condition. Re- 
 lief can be given in a short time if there is acute pain. 
 
 TREATMENT. The treatment is similar to that given under 
 endometritis. The bony lesions should be corrected; in short, 
 any lesion interfering with the normal nervous connection should 
 be removed. This is accomplished by CORRECTING THE BONY 
 LESION or by working directly over the structures and viscera. 
 OBSTRUCTIONS to the proper return of blood to the heart should 
 be removed. These can be removed by work directed to the 
 intestines, lifting them out of the true pelvis and working direct- 
 ly over the deep veins of the abdomen. Advise the patient to 
 keep off her feet as much as possible and to be out in the open air 
 a great deal. The fresh air is exhilarating and builds up the 
 quality of the blood, which is very helpful. Hermann says that 
 there is NO DRUG that has any specific effect upon subinvolution 
 or chronic metritis. 
 
 The UTERINE DISPLACEMENTS should be corrected, since the 
 congestion depends to a certain extent upon the twisting of the 
 broad ligaments which impinges the blood vessels. MASSAGE 
 of the uterus is highly recommended by some osteopaths. If 
 properly given it is quite helpful in restoring normal circulation 
 through the uterus, and tone to its ligaments. A quantity of 
 retained secretions can be worked out of the uterus by carefully 
 manipulating it.
 
 METRITIS. 363 
 
 The patient should avoid exposure during the monthly sick- 
 ness. There is an increased congestion at this time, consequent- 
 ly all the symptoms of metritis are aggravated. The GENU- 
 PECTORAL position is helpful and should be taken at least once 
 each day since the uterus partially empties itself of blood while 
 the patient is in this position. ABDOMINAL TREATMENTS are best 
 given while in this position, since gentle work over the abdo- 
 men helps the return circulation by relieving the pressure of the 
 intestines. 
 
 Attention to the action of the bowels is important. A dis- 
 tended rectum and sigmoid flexure favor a localized venous con- 
 gestion and are partly to blame for some of the varied disturb- 
 ances which are found in connection with uterine diseases. The 
 practice of using WARM WATER IN VAGINAL douches and the pro- 
 duction of scarification of the uterus are not to be recommended. 
 Depletion by means of leeches and counter-irritants are not in- 
 dicated, and are productive of more harm than good.
 
 364 DISEASES OF WOMEN. 
 
 ACUTE INFLAMMATION OF THE UTERUS. 
 
 ACUTE INFLAMMATION OF THE UTERUS is character- 
 ized by fever, distention of the abdomen, cessation of secretions 
 at first, and pain, either local or reflex, usually referred to the 
 stomach, liver, or small intestines. The patient lies with the 
 limbs drawn up, the abdominal muscles being very tense 
 and very much contracted. The appetite is lost and the 
 stomach deranged. On local examination the VAGINAL walls 
 are found to be VERY HOT to the touch. The UTERUS is very 
 TENDER, FIXED and the ligaments tense. Displacement, which 
 has come on suddenly, is usually found, and is in most cases a 
 prolapsus, resulting from running or a fall. Immediate conges- 
 tion ensues, pelvic pain becomes intense and within a few hours 
 the signs of inflammation are apparent. In many of these cases, 
 a chronic uterine displacement was primary; the exciting cause 
 exaggerating the malposition. In other cases the acute METRI- 
 TIS is due to SPECIFIC infection which traveled from the vagina 
 to the uterus. In such cases the vaginal symptoms of gonorrhea 
 are present in addition to the inflammation of the uterus and its 
 adnexa. By correcting the displaced uterus and relaxing the 
 muscles over the lower lumbar and sacral regions, the fever can 
 be reduced and the inflammation relieved. The writer has cured 
 most of his cases of acute inflammation of the uterus which were 
 brought on by sudden displacements, by FIRST REPLACING THE 
 UTERUS, then placing the patient in the genu-pectoral position, 
 and while in that position, WORKING OUT THE CONGESTION. 
 
 The other IMPORTANT CAUSE of acute metritis is EXPOSURE 
 DURING the menstrual flow. It may be only a chilling of the
 
 ACUTE INFLAMMATION OF THE UTERUS. 365 
 
 body but the quantity of the flow is affected. Anything that 
 results in catching cold at that time may stop the flow and pro- 
 duce inflammation. If the flow is suddenly checked inflamma- 
 tion is almost sure to follow. 
 
 In the treatment of acute metritis the use of hydroscopic 
 agents, such as glycerine tampons, is advised. I have used with 
 success such agents, that is, they relieved temporarily until I 
 could adjust the displacement. If used to excess, they ARE IN- 
 JURIOUS in that the tampons dilate the vagina, thus weakening 
 the supports of the uterus. If the uterus is ADHERED, ENGORGED 
 and FIRM, REPEATED ATTEMPTS at replacement are indicated, 
 until it is replaced or reduced in size. If the uterus is very tender 
 care should be exercised as to the amount of force used. Some 
 advise the use of a very large sound but it is extremely doubtful 
 if any good is accomplished by it. I rather think harm results. 
 The menstrual flow should be established as soon as possible as 
 this relieves the intense pelvic engorgement. This flow is not a 
 regular menstruation but rather a metrorrhagia. The digital 
 local treatment is usually sufficient to start the flow. The ab- 
 dominal treatment is similar to that given in chronic metritis 
 except that more care must be exercised on account of the per- 
 itonitis.
 
 366 DISEASES OF WOMEN. 
 
 SU BIN VOLUTION. 
 
 SUBINVOLUTION of the uterus is an enlarged condition, 
 which is the result of an IMPERFECT CONTRACTION or involution 
 after childbirth or abortion. In a typical case, the involution 
 should be complete within six weeks after delivery, but in a great 
 many cases, especially if there was a laceration and the patient 
 not very robust, it takes a much longer time. The muscular 
 elements, which were enormously increased in size and number, 
 fail to undergo atrophy and absorption; the blood vessels are 
 engorged and the lymphatics distended. The connective tissue 
 is increased in amount and the uterine walls remain thick. The 
 enlargement is, as a rule, symmetrical, but in some cases it is 
 confined to one part, principally the cervix. This form, when 
 occurring in the cervix, may be mistaken for a prolapsus. The 
 uterine cavity, as in the fibroid tumor, is enlarged. 
 
 CAUSES. The causes of subinvolution are BONY LESIONS 
 affecting the innervation of the uterus, ACCIDENTS, or complica- 
 tions of labor, and NEGLECT during the PUERPERIUM. The bony 
 lesions will prevent proper involution even though great care be 
 taken of the woman during the lying-in period. These lesions 
 are similar to other bony lesions which affect uterine circulation, 
 namely, subluxations of the lumbar vertebrae, sacrum, innomi- 
 nates or coccyx. 
 
 Recently a case of subinvolution came under my observa- 
 tion, the result of a displaced coccyx which occurred at child- 
 birth. This kept up a constant irritation of the perineum re- 
 sulting in congestion of the pelvic floor, vagina and uterus, thus 
 hindering CONTRACTION of the uterus.
 
 SUBINVOLUTION. 367 
 
 RISING from the bed VERY EARLY, standing on the feet too long 
 or over exertion too soon after delivery are common causes. How- 
 ever, these causes depend to a certain extent upon the above men- 
 tioned bony lesions. If these lesions did not exist the exciting 
 cause would not act so readily. Lacerations cause congestion, 
 hence a disturbance of the normal involution of the uterus. A 
 resumption of the marital relations soon after delivery is a com- 
 mon cause. In such cases, the menses are re-established within 
 a few months and of course along with this marked uterine en- 
 gorgement. The uterus is thus kept congested, there being no 
 chance given it to properly involute. Frequent pregnancies are 
 liable to be attended by subinvolution on account of loss of tonic- 
 ity of the muscular walls from frequent distention. Another 
 very important, possibly the most important cause, bony lesions 
 excepted, is the non-nursing of the mother by the new born baby. 
 
 ABOUT 60 per cent, of all babies born of mothers who do not 
 have to do manual work for an existence, are bottle fed. SUB- 
 INVOLUTION, not only of the uterus and its adnexa, but of the 
 ABDOMINAL wall, is present in nearly every case. THE NURSING 
 
 OF THE CHILD HAS A MARKED EFFECT ON UTERINE CONTRACTION 
 WHICH IS NECESSARY TO PERFECT INVOLUTION. This is proven 
 
 by the fact that for a week or more after labor the LOCHIAL DIS- 
 CHARGE is increased in amount at each nursing. The after pains 
 are worst at the time of nursing, and on palpation the uterus can 
 be felt as a firmly contracted body. The stimulus to the nipple 
 resulting from the nursing reflexly contracts the uterus, hence 
 in cases in which the mother does not nurse the child these stim- 
 uli are absent and as a consequence the uterus remains large, 
 which condition is called subinvolution. The ABDOMINAL WALL 
 BECOMES FLABBY and PENDULOUS; the patient has a bad form. 
 All the various kinds of abdominal binders would not prevent
 
 368 DISEASES OF WOMEN. 
 
 this in the above sort of case. The PELVIC FLOOR remains stretch- 
 ed, causing a weakening of the uterine supports. These things 
 can in a measure be prevented. The child should be nursed dur- 
 ing the puerperium if it is possible to do so, even though there are 
 some contraindications. 
 
 CHILDBED FEVER, if permitted to occur, is followed by a con- 
 gestion and subinvolution of the uterus. Retention of secundines 
 or a prolonged labor weaken the walls of the uterus and prevent 
 its proper contraction after childbirth. 
 
 SYMPTOMS. NEARLY EVERY SYMPTOM, both constitu- 
 tional and local, which comes from a uterine affection ATTENDS 
 A SUBINVOLUTION. PAIN, aches in lumbar and sacral regions, 
 pelvic distress and bladder disturbances are common; constipa- 
 tion, hemorrhoids, anorexia and nausea are found; chronic in- 
 flammation of the uterus with its attending evils follow as a re- 
 sult of the congestion; abnormal secretions and menstrual dis- 
 orders exist. The MOST COMMON MENSTRUAL disorder is MEX- 
 ORRHAGIA, the next dysmenorrhea. The health is undermined 
 and the patient feels weak and of no account. There is ina- 
 bility to concentrate the mind and tendency to forget names. 
 SLEEP DOES NOT REFRESH and the patient awakes with a back- 
 ache. The limbs feel heavy and there is difficulty in walking. 
 Various reflex nervous phenomena are present. These nervous 
 indications vary in degree from a mild form of restlessness to the 
 hysterical convulsions. If laceration is the primary cause these 
 nervous phenomena are more marked. Anemia soon develops 
 with its weakness and sense of exhaustion. If a patient were 
 to come into the office suffering with the above symptoms dating 
 from childbirth, subinvolution should be suspected with lacera- 
 tion as a cause. 
 
 DIAGNOSIS. On digital examination the CERVIX is FOUND
 
 SUBINVOLUTION. 369 
 
 TO BE LARGE AND SOFT. The os is very patulous, sometimes ad- 
 mitting the examining finger. This PATULOUS CONDITION of 
 the external os may come from other causes, such as SEXUAL EX- 
 CESSES, and thus mislead the physician as to the real cause. Dur- 
 ing sexual congress the uterus descends and the os dilates. Re- 
 peated dilation soon results in a permanent enlargement to which 
 is given the term patulous. The cervix is very much thickened 
 and shortened and feels like a round blunt body. Tenderness is 
 present, due to the inflammation which usually accompanies the 
 condition. When the uterus is outlined it is found to be consid- 
 erably larger and softer than the normal. 
 
 On account of the lack of tone, both in the uterine walls 
 and ligaments, retro-displacement and prolapsus are usually 
 present. The form of retro-deviation is commonly a retroflexion. 
 The writer has seen many cases in which the fundus was on a 
 level with the umbilicus. By pressure on the posterior part of 
 the uterus through the posterior fornix or rectum the impulse 
 would be transmitted to the external hand placed at the um- 
 bilicus. The HISTORY of the trouble will aid in the diagnosis. 
 If, as mentioned above, the trouble dates from parturition, the 
 patient getting up a few days after delivery, and a laceration is 
 present, although it can occur without it, and the uterus is found 
 in the above described condition, subinvolution is probably the 
 condition. 
 
 The patient should be kept in bed at least NINE DAYS after 
 delivery, regardless of her apparent strength, for the uterus is 
 usually too heavy before the end of a week to be held in position 
 by the weakened ligaments while she is in the erect posture. 
 There can be given no hard and fast rule regarding the number of 
 days that the patient should be kept in bed, for one patient may 
 
 get up before the end of a week and no apparent evil effects fol- 
 21
 
 370 DISEASES OF WOMEN. 
 
 low; another may do likewise and become a chronic invalid, so, 
 to be on the safe side, keep her in bed at least nine days, or as 
 much longer as is necessary for her to recuperate. 
 
 TREATMENT. The treatment is similar to that outlined 
 for chronic inflammatory conditions of the uterus. BONY DIS- 
 PLACEMENTS should be corrected and the patient should rest as 
 much as possible. Treatment should also be given over the course 
 of the veins returning the blood to the heart. The pelvic floor 
 may be strengthened by a strong stimulating treatment in the 
 lumbar and sacral regions to free and stimulate the nerve force 
 to the muscles comprising the floor. Separating the knees against 
 resistance strengthens the muscles. A MUSCLE FIBER RELAXES 
 
 WHEN THE AMOUNT OF NERVE FORCE TO IT IS LESSENED. Ill 
 
 subinvolution, the lesions mentioned interfere with or shut off 
 these nervous impulses, the muscle fibers remaining relaxed and 
 large. Correction of these lesions is necessary in order to get 
 proper contraction of the muscle fibers of the uterus. The stim- 
 ulating treatment referred to above, helps temporarily. 
 
 To temporarily relieve the congestion, place the patient in 
 the knee-chest position while giving the abdominal treatment, 
 which consists principally of lifting the viscera out of the true 
 pelvic cavity. It is advisable to instruct her to assume this posi- 
 tion for several minutes each night just before retiring. This 
 lessens the congestion and diminishes the weight of the uterus. 
 The uterus, if found displaced, should be put in its proper posi- 
 tion. If it does not stay in place, and it probably will not, it 
 should be replaced every week or so, this depending however, on 
 the character of the symptoms. By replacing the uterus the 
 passive congestion isgreatly relieved. If LACERATION is the cause 
 of the congestion and subinvolution, treatment should be directed 
 to it, since the subinvoluted condition will exist as long as the 
 irritation remains.
 
 SUPERINVOLUTION'. 371 
 
 SUPERINVOLUTIOX. 
 
 SUPERIXVOLUTION is a condition just the opposite to that 
 of subinvolution of the uterus. As the word implies, it is too 
 rapid or excessive involution. It is usually found following par- 
 turition, but some cases are due to senile atrophy. It is a rare 
 condition and is probably connected with abortion more fre- 
 quently than with parturition. The uterus shrinks or contracts 
 beyond the physiological limit, becoming very small, degenera- 
 tion setting in, all of which conditions combine to make it soft and 
 excessively mobile. The non-puerperal atrophy is sometimes 
 caused by pressure from a fibroid tumor or it may be the result 
 of an operation. Menstruation is affected, there being amen- 
 orrhea or a scanty flow. STERILITY is a sequel if it occurs be- 
 fore the climacteric. Some patients complain of various reflex 
 disturbances, but these are rare as compared with other uterine 
 affections, since there is little or no inflammation in the uterus. 
 Treatment should be directed to a building up of the general sys- 
 tem and increasing the nutrition of the uterus. In the senile 
 atrophy which occurs after the change of life, few symptoms are 
 present, it being a physiological process. In these cases treat- 
 ment does little or no good and is seldom indicated.
 
 372 DISEASES OF WOMEN. 
 
 PERIMETRITIS. 
 
 PERIMETRITIS is an inflammation of the PELVIC PERI- 
 TONEUM, called also LOCAL PELVIC PERITONITIS. It is a very 
 frequent disease and one which results in the formation of ad- 
 hesions which fix the uterus to some neighboring structure. It 
 is usually a localized affection, being confined to that part of the 
 peritoneum covering the uterus. The parietal layer of peri- 
 toneum lining the abdominal wall is continued as a layer over the 
 pelvic structures, the dipping of this layer between the pelvic 
 viscera constituting the ligaments of the viscera. The FUNC- 
 TION of the pelvic peritoneum is to permit free motion and to sup- 
 port, hence two forms of disorders result from a perversion of its 
 function, viz., TOO FREE MOBILITY and LESSENED MOBILITY. The 
 first permits of displacements, especially prolapsus. The second 
 is the more pathological of the two because of the inflammation 
 which is, or was, present. The uterus is like a joint it has liga- 
 ments and mobility. If mobility CAN BE RESTORED to the uterus 
 (or joint), its function will be normal and congestion and inflam- 
 mation disappear. An inflamed uterus is seldom if ever mobile. 
 
 When inflammation of the peritoneum sets in, nature pre- 
 vents the diffuse form of peritonitis by forming an exudate, 
 thus producing adhesions WHICH LOCALIZE the inflammation. 
 It, like inflammation of other serous surfaces, is first preceded by 
 congestion followed by effusion, that is, the throwing out of the 
 exudate. This exudate becomes organized and forms scar or 
 fibrous tissue. It is very similar to pleuritis as to cause, path- 
 ology and termination, that is there is an inflammation of adja- 
 cent organs, secretory changes and the formation of adhesive
 
 PERIMETRITIS. 373 
 
 bands. It is regarded as a very important disease, for certainly 
 in point of frequency it is second only to endometritis. 
 
 CAUSES. The causes of perimetritis depend upon a disturb- 
 ed uterine circulation. This disturbance is usually the result of 
 uterine inflammation. The inflammation spreads by continuity 
 of tissue, to the peritoneum covering the uterus. In ACUTE IN- 
 FLAMMATION of the uterus ALL THE PELVIC CONTENTS are more or 
 less inflamed. If a displacement exists the inflammation more 
 rapidly spreads to the peritoneum, and in almost every case ad- 
 hesions form. 
 
 Specific infection reaches the peritoneal cavity by way of the 
 Fallopian tubes and sets up a chronic form of inflammation which 
 is very intractable. Fluids also escape into the peritoneal cav- 
 ity in the same way. Injections, and especially medicated so- 
 lutions forced into the uterus, have resulted in a part of the fluid 
 escaping into the peritoneal cavity and setting up an inflamma- 
 tion. 
 
 ENDOMETRITIS also produces this local form of peritonitis 
 by the inflammation spreading to the peritoneum through the 
 Fallopian tubes. Any cause that produces endometritis, espec- 
 ially the acute form, will cause perimetritis. ACUTE METRITIS 
 invariably results in peritoneal adhesions. In such cases there 
 is present everything necessary, such as an exudate, proximity 
 from enlargement, fixation and inflammation. 
 
 The ACUTE CASES depend, in most instances, on a SUDDEN 
 DISPLACEMENT of the uterus, which sets up an acute congestion 
 and inflammation of the uterus and neighboring structures. 
 Sometimes general peritonitis results or inflammation of the 
 bowels follows. Exposure during the menstrual flow causes a 
 congested condition of the ovaries and other pelvic organs. If a 
 general inflammation is produced it becomes localized as it re-
 
 374 DISEASES OF WOMEN. 
 
 cedes and adhesions form. INFLAMMATION OF THE BOWELS fre- 
 quently spreads to the pelvic organs and there sets up secondary 
 inflammatory changes. 
 
 SYMPTOMS. In ACUTE cases the symptoms are those of an 
 acute metritis, viz., great tenderness of the abdominal walls, 
 swelling of the abdomen, contraction of the abdominal muscles, 
 chills, fever and localized pain. The pain may be colicky and 
 referred to the intestines. The limbs are drawn up to relieve 
 the traction on the abdominal muscles. The symptoms may 
 simulate appendicitis and on this account care should be taken 
 in the diagnosis. The vaginal walls are hot and the uterus fixed 
 by the contracted ligaments. If this condition is allowed to con- 
 tinue, death will ensue from diffuse peritonitis. After the acute 
 symptoms have abated, the exudate becomes hardened and 
 undergoes structural changes, soon forming scar or fibrous tissue. 
 These adhesions between the layers of the peritoneum prevent 
 motion of the uterus and at first it is fixed in one position, which 
 gives it a board like feeling. They soon begin to be absorbed, 
 but a few remain on the side in which there was the greatest in- 
 flammation and tend to draw the uterus and fix it toward that 
 side. The patient complains of a DRAWING OR PULLING SENSA- 
 TION in the affected side. The uterus gradually regains more 
 freedom of motion the longer the adhesions exist, unless new ones 
 form, since they are stretched with each jar and movement of 
 the body. In some cases the uterus, when retroverted, is bound 
 down to the rectum and adjacent structures by these adhesions. 
 
 By examination through the fornices they can sometimes be 
 felt. On rectal examination the posterior adhesions can be out- 
 lined if they are much thickened. If examination is made with 
 the patient in the genu-pectoral position, the adhesions will feel 
 as cords, made tense by the uterus falling away from the rectum.
 
 SUBINVOLUTION. 375 
 
 In the dorsal position the uterus if normal should be freely mov- 
 able in all directions. By testing this mobility and noticing the 
 side in which there is restriction of motion the location of the adhes- 
 ions can thus be ascertained. Sometimes in bad cases the UTERUS 
 is IMMOVABLE, it being held as in a vice. 
 
 The reflex symptoms are those found in inflammatory con- 
 ditions of the uterus, such as sideaches, backache, headache and 
 nervous phenomena. STERILITY is the result and MENSTRUAL 
 DISORDERS, especially dysmenorrhea, are frequent. 
 
 PROGNOSIS. In the acute form the DANGER LIES in it be- 
 coming a DIFFUSE PERITONITIS. If the inflammation can be 
 checked, it will become localized by the exudation and adhes- 
 ions which are formed. These adhesions which hold the uterus 
 in one position should be absorbed or broken up if the inflammation 
 has entirely receded. ABSORPTION is a slower but safer process, and 
 when it can be accomplished good results follow. As long as the 
 lesions exist, the patient will be troubled with various reflex pains 
 which accompany displacement and inflammation of the uterus. 
 
 TREATMENT. The treatment, in the acute stage, is to cor- 
 rect the displaced uterus if it exists, then relaxing the contractured 
 muscles found along the lower part of the spine. Work around 
 the inflamed parts lessens the congestion and tenderness. The 
 treatment then can be gently given over the point of inflammation. 
 By gradually and steadily increasing the pressure, the inflamed 
 organs can be manipulated, and when this can be done, the in- 
 flammation can be w r orked out. 
 
 In the chronic form, treatment applied to the lower lumbar 
 region is beneficial since it promotes a better pelvic circulation. 
 Any treatment that increases the arterial circulation increases 
 the absorptive qualities and this is necessary if the adhesions are 
 to be absorbed. This is the proper way to treat adhesions, that
 
 376 DISEASES OF WOMEN. 
 
 is, BY INDUCING ABSORPTION. Another method is to break up 
 the adhesions by GRADUALLY STRETCHING them or by USING 
 FORCE. There is danger in breaking them up suddenly, since 
 hemorrhage and inflammation may result. This hemorrhage is 
 in the peritoneal cavity and may excite a diffuse peritonitis. By 
 gently stretching the adhesions every few days and by increasing 
 the pelvic circulation, which things are accompanied by repeated 
 attempts at replacement, the fibrous tissues, which are the re- 
 sult of the inflammatory exudates, will gradually disappear. 
 The adhesions are stretched easily by movements of the uterus 
 as obtained by local treatment, or deep massage over the uterus 
 through the abdominal wall. In case of adhesions fixing the 
 uterus in retroversion, the uterus can be moved forward by rec- 
 tal treatment. By gently pushing the uterus forward these ad- 
 hesions will be thinned by constant stretching, and finally dis- 
 appear. 
 
 Abdominal treatment given directly over the uterus, stim- 
 ulates uterine contraction and betters the pelvic circulation. 
 The uterus can be moved in this way, a thing to be desired in the 
 treatment of adhesions. CIRCULAR MASSAGE over the uterus is 
 one of the best ways to induce uterine contraction. I rely upon 
 it in most cases of post partum hemorrhage. 
 
 Since METRITIS complicates most cases of endometritis, the 
 uterus is found congested and enlarged. From this it can be 
 seen that any treatment that excites uterine contraction increases 
 uterine circulation, hence absorption. In these cases as in others, 
 the real trouble and cause must be corrected. The frequency 
 of treatment depends upon what is done at a treatment. If ad- 
 hesions are broken up, wait a few days before giving another 
 treatment or you may set up a fresh inflammation. If only the 
 congestion is reduced, frequent treatment should be given. If a
 
 PERIMETRITIS. 377 
 
 bone is set at the first treatment, leave it alone. If the bony lesion 
 is not corrected, treat it again soon, unless inflammation exists. 
 
 Adhesions are frequently met with and are very hard condi- 
 tions to cure. By constantly stretching them they can be grad- 
 ually broken up and absorbed, but care should be exercised LEST 
 THE INFLAMMATION BE MADE WORSE, hemorrhage produced; 
 followed by a fresh attack of peritonitis. The question is often 
 asked, when should an adhesion be broken up? In cases of DIS- 
 PLACEMENTS PRODUCING MECHANICAL OR REFLEX SYMPTOMS, 
 in which the uterus is held down by adhesions, even though there 
 is little or no inflammation, they should be broken up. If the 
 uterus is displaced and there is very much inflammation the ex- 
 isting adhesions SHOULD BE ABSORBED. If the uterus is in its 
 normal position it is not likely that adhesions exist, but if they 
 do they may cause trouble and should be broken up. As a rule 
 all cases of displacement which are complicated by these adhe- 
 sions should be treated. 
 
 In many cases, especially in the early stages, there is an ex- 
 udation of an agglutinating nature which sticks or glues the per- 
 itoneal surfaces together. In such cases simply place the patient 
 in the knee-chest position and direct a few light blows on the 
 lumbo-sacral region, thus causing the peritoneal surfaces to sep- 
 arate and the uterus to be replaced. 
 
 ADHESIONS uniting the cervix to the vaginal walls are fre- 
 quently found. I had a case recently in which the cervix could 
 not be outlined, the fornices being completely filled with inflam- 
 matory exudates. The uterus was immavable and very much 
 inflamed. These conditions usually result from a long standing 
 vaginitis. In the above case the woman had had uterine dis- 
 ease for years. 
 
 The DIAGNOSIS can be made by digital examination or by
 
 378 DISEASES OF WOMEN. 
 
 the use of the speculum. On vaginal examination only a slight 
 elevation or protrusion in the upper part of the vagina can be 
 felt. The parts are tender, the degree of soreness depending upon 
 the amount of inflammation. The cervix can not be encircled 
 with the examining finger and the os is found as a depression 
 at the uterine end of the vagina. The usual symptoms of me- 
 tritis are present. 
 
 These kinds of adhesions are treated in a way similar to per- 
 itoneal adhesions, that is, by increasing the blood supply and 
 gradually breaking them up. By attempting to encircle the 
 cervix with the internal finger the adhesions can be readily reach- 
 ed and stretched or broken up unless the case is very chronic. 
 In these chronic cases the adhesions are so fibrous that it is hard 
 to get absorption or even break them up. In such cases the 
 treatment should be directed to relieve the inflammation if any 
 exists. If these vaginal adhesions are causing very little or no 
 trouble, TREATMENT is NOT INDICATED. If they fix the uterus 
 in an abnormal position or there is a co-existing inflammation of 
 the uterus, they should be removed if possible.
 
 PHYSIOLOGICAL PERIODS. 379 
 
 PHYSIOLOGICAL PERIODS. 
 
 THE LIFE of a woman is divided into certain physiological 
 periods. The period to puberty, varying from ten to fifteen years, 
 is called infancy or childhood. The commencement of the per- 
 iod of sexual activity, usually about thirty years in length, is 
 called maturity. The menopause or climacteric indicates the 
 cessation of sexual activity and menstruation. The period fol- 
 lowing the change of life is called senility. The two most im- 
 portant are the TRANSITIONAL periods, puberty and the meno- 
 pause, for at these times great nervous changes take place, ac- 
 companied by various reflex phenomena and anatomical changes. 
 On account of these nervous changes disease at these times is 
 liable to get a foothold and is very hard to relieve. 
 
 INFANCY. During the period of life up to puberty the 
 sexual organs are PHYSIOLOGICALLY DORMANT. The uterus is 
 small and non-developed and the ovaries in a condition of inac- 
 tivity. The mammary glands have not begun to enlarge; hair 
 has not begun to appear on the mons Veneris, and the greater 
 lips are not fully developed, so that the lesser lips protrude be- 
 yond the vulva. During this period the evil practices such as 
 masturbation are frequently contracted. If it is near puberty, 
 it brings on premature activity of the sexual apparatus. The 
 clitoris becomes congested and in some cases inflamed. Ad- 
 hesions frequently form which result in some cases in a hooded 
 clitoris. This causes a loss of nerve force and is associated with 
 various nervous diseases, such as spasms and chorea. 
 
 PUBERTY. Puberty is that period at which the genital 
 organs are capable of exercising their physiological function.
 
 380 DISEASES OF WOMEN. 
 
 This varies in different races and countries. In cold countries 
 puberty develops late, that is, on an average of about the age of 
 thirteen or fourteen. In temperate climates it occurs at about a 
 somewhat earlier age. In warm climates it comes quite early. 
 Girls reared in the country as a rule develop late. On the con- 
 trary, girls in the cities develop early on account of the associa- 
 tion, kind of food and general excitement of city life. At PU- 
 BERTY the UTERUS and APPENDAGES UNDERGO GREAT STRUC- 
 TURAL CHANGES. The organs that were hitherto dormant and 
 undeveloped, become active and increase in size; the nervous 
 system becomes dominant and is susceptible to external influ- 
 ences. 
 
 The progress of development of the two sexes up to the tenth 
 or eleventh year is equal. The boy develops imperceptibly from 
 youth to manhood without any special disturbances. The fe- 
 male, on the contrary changes rapidly to womanhood and her 
 nervous system is taxed to maintain the equilibrium and proper 
 development of the sexual organs at the same time. The nerve 
 force that ought to be used for their development should not be 
 directed into other channels or else the pelvic organs suffer. It 
 is a critical time and UPON ITS NORMAL TERMINATION DEPENDS 
 MUCH of the after HEALTH and FREEDOM FROM UTERINE disease. 
 A great many women date their trouble back to puberty. They 
 have never menstruated properly and if, in such cases, the his- 
 tory can be obtained, there will be found something that pre- 
 vented the normal approach of puberty, such as overwork, both 
 mental and physical, exposure or accident. 
 
 Puberty is marked by a change in the pelvis. The hips 
 broaden and the form becomes rounded from the accumula- 
 tion of fat; hair appears on the pubis and labia majora, and the 
 mammary glands begin to enlarge; the ovaries become increased
 
 PHYSIOLOGICAL PERIODS. 381 
 
 in size and both the blood and nerve supply to them is increased 
 in amount; ovulation begins, and with it the appearance of men- 
 struation. These things are indicative of the sexual nervous 
 system approaching that maturity which makes a woman capa- 
 ble of procreating. During the change of puberty the patient 
 sometimes becomes anemic, the appetite abnormal in that there 
 is a craving for peculiar kinds of food, eruptions appear on the 
 face, and she complains of weakness and lassitude. The symp- 
 toms should disappear if the change to maturity is normally made, 
 but this is not the case in many patients, who remain weak and 
 nervous on account of the unequal nervous distribution. As a 
 result of this, bony LESIONS ARE READILY produced at this time, 
 because the muscles and ligaments are flabby and relaxed. 
 
 MATURITY comprises that period between puberty and the 
 menopause or the fruitful period of a woman's life. It should be 
 the period of least disease and disturbance, since it is one of great 
 physiological activity, yet menstrual disorders and inflammatory 
 conditions are frequently found. 
 
 If the function of childbearing is not interfered with by 
 artificial means, the woman will have perfect health unless acci- 
 dents, strains or injuries occur. A woman is predisposed to dis- 
 ease after she reaches the age of thirty if she has not borne children. 
 CHILDBIRTH changes her nervous system, alters her in various 
 ways and fulfils the function for w r hich she was designed. A 
 great many diseases are contracted, and they are on the increase, 
 as a result of interference with this function. The accidents of 
 childbirth, such as laceration, which occur during this period, 
 may be the foundation of future disease. The period of matur- 
 ity is comparatively free from neuroses and the various mental 
 and imaginary diseases. It is rare to get a case of hysteria in a 
 woman who has borne children unless there has been a laceration
 
 382 DISEASES OF WOMEN. 
 
 which has not healed. The suffering and changes produced make 
 her able to control herself. FIBROID TUMORS are the most com- 
 mon of the growths which occur during this period. 
 
 THE MENOPAUSE is the period at which menstruation 
 ceases. The average age at which the change of life occurs is 
 FORTY-FIVE. It is also called the CLIMACTERIC, which is taken 
 from a word meaning the top round of the ladder. It is a physiol- 
 ogical process and marks the close of the sexual activity of the 
 woman. The popular opinion is that the later the menses com- 
 mence the later the menopause occurs, but in fact just the op- 
 posite exists. If, in a woman who is fully developed, the menses 
 come on late, the period of sexual activity will be short, that is 
 the menopause will appear at about the age of forty. The ex- 
 planation offered is, that the stronger the sexual organs the longer 
 they will retain their power of reproduction, hence menstruation 
 will continue longer. The weaker the generative organs, the 
 later the puberty, the shorter the period of maturity and the 
 fewer pregnancies. 
 
 The LENGTH of the MENOPAUSE varies. Usually it covers a 
 period of from ONE to TWO years; in extreme cases it lingers 
 through a period of several years. The writer has treated many 
 cases in which the change of life lasted from five to ten years. 
 Cold climates delay puberty and produce an early menopause; 
 warm climates have the reverse effect. The AVERAGE NUMBER 
 of CHILDREN PER FAMILY is less in cold than in warm climates. 
 
 The cause of the menopause is in most cases a physiological 
 one, but it may be ARTIFICIALLY PRODUCED. At this time the 
 ruling organs, the ovaries, cease their activity, hence the stim- 
 ulus which the uterus receives from the ovaries is absent. Im- 
 pregnation is no longer possible, therefore menstruation is un- 
 necessary. The removal of the ovaries by operation, or a struc-
 
 PHYSIOLOGICAL PERIODS. 383 
 
 tural disease of them, brings on a premature menopause. The 
 operation called ovariotomy is often resorted to in uterine dis- 
 ease. Wasting diseases, shock, either physical or mental, which 
 unfit the woman for childbearing, often bring on a premature 
 menopause, especially if she is already approaching it at the time 
 of accident. Chronic metritis predisposes to an early menopause, 
 and one attended with various functional disturbances. 
 
 The ANATOMICAL CHANGES are based on the cessation of 
 ovarian influences; the uterus undergoes atrophy, becoming small 
 and hard. In premature menopause, and particularly that form 
 due to ovariotomy, the uterus is said to at first become a little 
 larger and heavier. Hyperemia exists, on which account the 
 menstrual disorders occur. The vagina also becomes injected 
 and swollen with increased secretion. The conditions last sev- 
 eral months, followed by atrophy. The VAGINA ATROPHIES, 
 becoming pale and losing its rugae; it shortens and becomes 
 narrower. The uterus gradually becomes smaller, especially 
 its vaginal portion. The changes occur earlier in premature or 
 artificial menopause than in the normal, the atrophic changes 
 being completed within a few months, particularly if the ovaries 
 have been removed. OBESITY results in about 80 per cent, of 
 all cases. NERVOUS PHENOMENA are common, ranging from 
 hysteria to insanity. The sexual function is impaired and 
 in a short time sexual feeling is lost. The vaginal canal becomes 
 so small in some cases that coition is no longer possible. In 
 others it closes entirely, giving rise to retention of the uterine 
 secretions. 
 
 The mucous membrane undergoes changes in which the 
 glandular elements are lost. In cases of metritis these atrophic 
 changes are lessened or even entirely absent, the uterus remain- 
 ing large and congested, giving rise to leucorrhea, often irritating,
 
 384 DISEASES OF WOMEN. 
 
 displacement and irregular hemorrhages. In the natural meno- 
 pause the vagina, having undergone senile atrophy, becomes 
 smaller and weaker. The walls are not held permanently to- 
 gether and as a result prolapsus or, in some cases, procidentia 
 occurs. The walls lose their rugae and a great part of their elas- 
 ticity. This is more marked in some cases which are preceded 
 by chronic uterine trouble covering a period of years. The for- 
 nices become shallow, and in some cases, entirely obliterated. 
 The cervix can with difficulty be outlined in such cases, it being 
 felt as a hardened body with a depression in its center corres- 
 ponding to the os uteri. The ovaries atrophy and the Graafian 
 follicles disappear. They become flattened and hardened and 
 are covered with scars, the remains of the rupture of the Graaf- 
 ian follicles. Dense fibrous tissue replaces the atrophied and 
 degenerated parts of the ovaries. The Fallopian tubes shrink 
 and become shorter, lose their ciliated epithelium, and some- 
 times the walls unite, thus obliterating the lumen of the tubes. 
 The vulva undergoes degenerative changes; the ostium vaginae 
 becomes patulous, thus exposing the vestibule. The BREASTS 
 degenerate, usually becoming smaller and flatter; the glandular 
 elements disappear and are replaced by fat in cases in which the 
 size is retained. The patient usually becomes obese but in some 
 cases there is loss of flesh. The tendency to the development of 
 malignant growths increases at this time. 
 
 Premature menopause is followed by obesity unless it is com- 
 plicated by other diseases. AMENORRHEA is frequently found in 
 obese women, the result of inactivity of the ovary, which is also 
 the probable cause of the obesity. It is a well known fact that 
 the more obese the patient, whether male or female, the smaller 
 the genitalia, particularly the ovaries or testes. Weakness of 
 these organs follows and in very obese women the FUNCTION is
 
 PHYSIOLOGICAL PERIODS. 385 
 
 SUSPENDED, that is, there is amenorrhea, sterility and atrophy 
 similar to that of the climacteric. The physiological changes 
 are those of cessation of function of the internal organs of genera- 
 tion, namely, cessation of menstruation and ovulation. 
 
 SYMPTOMS. The symptoms of the menopause may be 
 divided into two classes: First, the local symptoms which are 
 due to the menstrual changes; and second, the reflex or systemic 
 disturbances which are so common. The FIRST SYMPTOM of the 
 approach of the menopause is the irregular menstruation. The 
 menstruation may be delayed, it occurring at the fifth or sixth 
 week, or it may come on at any time. These menstrual changes 
 in a woman past forty constitute the CARDINAL INDICATIONS of 
 the approach of the menopause. The amount varies, sometimes 
 being increased, sometimes lessened, but there is usually hem- 
 orrhage. Sometimes the hemorrhage is so profuse that it threat- 
 ens the patient's life; in such cases cancer should be suspected. 
 
 The flow is prolonged, sometimes lasting from six to eight 
 days, and in some cases is continuous for several weeks. This 
 is an abnormal symptom and an examination should be made 
 lest there be a malignant disease. Irregular hemorrhages, called 
 metrorrhagia, may occur irregularly for years, sometimes the 
 patient skipping several months; it recurring after exertion. 
 Reed says that at the menopause lurking cancer advances by 
 leaps, and that any metrorrhagia at this time of life should ex- 
 cite suspicions of cancer. An OSTEOPATHIC TREATMENT, which 
 increases the blood supply to the pelvic organs, will frequently 
 bring on the flow even after it has ceased for a year. It is not an 
 alarming symptom, and frequently proves beneficial. This is 
 especially true in an abrupt cessation of the menses. If they do 
 not stop in the proper way, the patient will have trouble until 
 menstruation appears again. 
 
 25
 
 386 DISEASES OF WOMEN. 
 
 The reflex symptoms are many and cover the entire cate- 
 gory of reflected troubles. The CIRCULATORY changes are first 
 noticed. The head is congested, causing a flushed face, insomnia, 
 or a restless sleep disturbed by dreams. VERTIGO is common, 
 also a roaring and buzzing in the ears, or TINNITUS aurium. A 
 part of the body may become numb, the arm being the part most 
 frequently affected in this way. Eye sight is affected, it being 
 blurred, or spots appear in the field of vision. The character- 
 istic vaso-motor changes inducing hot and cold flashes or a local- 
 ized congestion are commonly present. The patient suddenly 
 breaks out into a cold perspiration usually localized along the 
 spinal column or the course of a rib. In some cases the head 
 becomes very hot, or a general increase of temperature may 
 occur. The heart is commonly attacked, causing palpitation, 
 tachycardia and dyspnea. It becomes very weak with the pulse 
 very indistinct, or it may become labored in its action. SYNCOPE 
 follows if the heart is much weakened, but it is seldom fatal. 
 This follows any mental shock such as a sudden fright. In such 
 cases the patient should be placed in the dorsal position, with 
 her head low, then the RIBS OVER THE HEART SHOULD BE RAISED, 
 giving the heart more room in which to work. An intense pru- 
 ritus vulvae is sometimes found, accompanied by a leucorrheal 
 discharge. This is the result of a disturbance of the circulation 
 of the vagina and vulva. The various mucous membranes of the 
 body become congested, resulting in a catarrhal condition. HEM- 
 OPTYSIS occurs in some cases, HEMATEMESIS in others. The 
 hemorrhoidal plexus of veins in case of piles, bleeds very freely 
 at this time. These various sensory and circulatory disturbances 
 are supposed to be due to a retention of blood which does not 
 find an outlet at the menstrual period. 
 
 The nerve force is deranged on account of the changed con-
 
 PHYSIOLOGICAL PERIODS. 387 
 
 dition of the pelvic circulation. Like the onset of menstruation, 
 the menopause is attended by marked nervous symptoms. Byron 
 Robinson says that a stormy puberty is followed by a stormy 
 menopause. These various changes manifest themselves in irri- 
 tability of temper, melancholia, hysteria and other mental dis- 
 turbances of different varieties. INSANITY, accompanying the 
 menopause, has been noted in some cases. Hysteria is a marked 
 symptom. The sexual appetite becomes inordinate, in some 
 cases leading to excesses. The patient's entire disposition is 
 changed, she frequently becoming peevish and fretful. This, 
 however, is not found in every case. 
 
 These VARIOUS REFLEX TROUBLES depend upon the strength 
 of the parts affected. IF A LESION DISTURBS THE INNERVATION 
 of the heart then the exciting cause, the circulatory and nervous 
 changes in the pelvic viscera will weaken it more. If neck le- 
 sions exist the circulation to the brain is altered, often to a patho- 
 logical degree. This, coupled with the changes in the pelvic 
 genitalia, leads to diseased conditions or perversions ranging 
 from a mere idiosyncrasy to insanity. The same may be said 
 of other forms of reflexes, There is usually a bony lesion affect- 
 ing the part, whether the stomach, lungs, bowels, or cerebral 
 circulation, which weakens it so that it cannot resist the ex- 
 citing causes which are at work. 
 
 The DANGERS of the menopause are the tendency to HEM- 
 ORRHAGE, and onset of MALIGNANT DISEASES, principally CANCER 
 of the uterus and breast. Every woman knows this and, on 
 this account, if there is an abnormal condition it injuriously 
 preys on her mind. On the other hand the MENOPAUSE CURES A 
 GREAT MANY PELVIC DISEASES. Dysmenorrhea in all its varied 
 forms disappears; inflammatory conditions abate on account of 
 the atrophic changes; fibroid tumors cease their growth, or atro-
 
 388 DISEASES OF WOMEN. 
 
 phy from lack of nourishment; various ovarian troubles are 
 cured, thus relieving the patient of pains which have made life a 
 burden. Such patients hail with joy the approach of the men- 
 opause. 
 
 The diagnosis of the approach of the menopause is made 
 by noting the irregular, scanty, or profuse menstruation and pecu- 
 liar reflex symptoms not before noticed by the patient. If these 
 symptoms appear in a woman between the ages of forty and fifty, 
 who has been previously healthy, suspect the menopause as the 
 cause. 
 
 TREATMENT. The treatment is palliative, that is. the 
 various symptoms can be relieved but not entirely cured until 
 the cessation of the flow. The symptoms should be treated as 
 they arise If the heart is weak, strengthen it by raising the 
 ribs and correcting the predisposing weakness. The hot flashes 
 are usually controlled by a spinal treatment and by work applied 
 to the pelvic organs, since these flashes are the result of some of 
 the pelvic disturbances. Vertigo, headaches, and the eye and 
 ear derangements can be helped by neck treatment, but the symp- 
 toms can not, as a rule, be permanently relieved until the change 
 of life is past. The hemorrhage, if excessive, is stopped by treat- 
 ment which produces uterine contraction. As mentioned above, 
 the menses may reappear after a hard treatment, but do not be 
 alarmed unless the hemorrhage is excessive or frequent, since 
 evil results seldom follow. 
 
 If the abnormal conditions of the change of life are due to 
 bony lesions, treatment should be given to correct these lesions. 
 In cases of chronic uterine disease these lesions are common and 
 do affect the menopause. Lesions which affect the other physic - 
 ogical functions of the uterus will certainly affect the menopause 
 and should be regarded as important causes in cases of abnormal 
 change of life.
 
 PHYSIOLOGICAL PERIODS. 389 
 
 The premature or acquired type of menopause is the form 
 that most frequently calls for treatment. The NATURAL or physio- 
 logical type is, or rather should be, FREE FROM SYMPTOMS severe 
 enough to warrant treatment. The produced or intentional 
 type is brought about by the removal of the ovaries or uterus. 
 This is done in order to relieve ovarian or uterine disease, dys- 
 menorrhea or menorrhagia, lessen the growth of uterine fibroids, 
 or to cure certain diseases which are supposed to depend 
 on a diseased condition of the ovaries or uterus, such as epilepsy, 
 insanity or excessive nervousness. It is of value in some of these 
 cases, especially if there is an abuse of the sexual organs, yet I 
 have seen many cases of insanity, epeilpsy and other diseases not 
 even benefited and some even made worse by bringing on a pre- 
 mature menopause by ovariotomy. The cystic ovary is the kind 
 most often operated on. 
 
 Premature menopause from causes other than operations 
 such as shock or wasting diseases, seldom produces such evil effects 
 as the above. If the result of mental shock , various functional 
 disorders, cerebral disturbances, backache and nervousness may 
 follow. I recall one case in which a mental shock at the men- 
 strual period brought on a premature menopause followed by a 
 very marked chronic eruption and ulceration of the skin. 
 
 Ovariotomy performed before the menopause has certain 
 effects that are fairly constant. MENSTRUATION usuallv CEASES 
 at once IF BOTH OVARIES ARE COMPLETELY REMOVED. Some- 
 times for a while VICARIOUS MENSTRUATION and molimina fol- 
 low. The menstrual molimina are most pronounced, and are 
 characterized by pain over the ovaries, in the breasts, head, back 
 and lower limbs, tinnitus aurium, vomiting, fainting and labor- 
 ed or otherwise disturbed heart beat. These symptoms are fol- 
 lowed by hot and cold flashes, or even flushings of the skin that
 
 390 DISEASES OF WOMEN. 
 
 are plainly visible. These thermic flashes are irregular and recur 
 several times per day. Localized perspiration, a sense of weak- 
 ness and thoracic oppression, leucorrhea in its worst form, are 
 present and the appearance of "mannish tendencies" are com- 
 mon if the ovaries are removed quite early, that is as young as the 
 age of twenty-five years. 
 
 The local effects of ovariotomy, or of the artificial menopause 
 induced by it, are: HYPEREMIA of the UTERUS continuing for 
 several months, characterized by hemorrhages of varying degrees, 
 and leucorrhea; ATROPHY and softening of the vaginal walls, on 
 which account the rugae disappear, the walls become dry and 
 the mucous membrane folded or prolapsed. The uterine atro- 
 phic changes are similar to those in the normal menopause, but 
 more rapid, obesity develops, the sexual function is perverted 
 or destroyed followed by depression of spirits, and the patient 
 is in a worse condition than she was before she was operated on. 
 In other cases a sense of drawing or contraction appears in the 
 groin as a result of the formation of scar tissue which contracts. 
 Sometimes this "pulling" as the patient describes it, is very pain- 
 ful and annoying. 
 
 The PRODUCTION of a PREMATURE menopause by ovariotomy 
 is indicated in a FEW CASES, but in most cases osteopathic treat- 
 ment does away with the necessity of an operation. In cases of 
 chronic disease of the ovaries, tubes or uterus, which do not re- 
 spond to treatment after a thorough trial, and which cause local 
 pain, menstrual disturbances or reflex phenomena to a pathol- 
 ogical extent, an operation is indicated, but such cases are few. 
 
 SENILITY is that period which follows the change of life. 
 It is a period of repose and one of PHYSIOLOGICAL INACTIVITY of 
 the sexual organs. In the early part of the period, malignant 
 growths are prone to occur. Any abnormal hemorrhage of the
 
 PHYSIOLOGICAL PERIODS. 391 
 
 uterus should be carefully investigated. Prolapsus is frequently 
 found, but causes comparatively little trouble. The cases of 
 COMPLETE PROCIDENTIA are most frequently found during this 
 period. The patient is usually free from the ordinary uterine dis- 
 turbances and cancer is about the only disease to be feared. Oc- 
 casionally during this period prolapsus and retroversion produce 
 marked reflex symptoms, such as an intense backache, headache 
 or queer feelings in the head, loss of memory and symptoms sug- 
 gestive of softening of the brain. Sometimes fibroid tumors 
 appear even at this late age, but only in cases of uterine injury 
 or disease. 
 
 OVULATION is the process which includes the maturing of 
 the Graafian follicle, its rupture, escape of the ovum and its 
 transmission to the uterus, although it may drop down into the 
 peritoneal cavity and there perish. Reed says "paradoxical as 
 it may appear, it may be well said that nowhere in the body do 
 we have a physiologic process with such typical pathologic feat- 
 ures as are found in ovulation." He further states that "after 
 a Graafian follicle matures there is a rupture and hemorrhage fol- 
 lowed by formation of cicatricial tissue." It begins at puberty, 
 or rather, puberty depends upon the beginning of ovulation. This 
 occurs bet\veen the thirteenth and fifteenth years. 
 
 In most animals, OVULATION is a periodic process occuring 
 in certain seasons and marked by increased sexual activity. In 
 the woman, and many domesticated animals, this relation does 
 not exist and ovulation occurs at no stated period. Some be- 
 lieve that it is a periodic phenomenon occurring every month. 
 This is the time of most common occurrence but it may take place 
 at any other time. This has been proven by post mortem exami- 
 nations revealing fresh scars on the ovaries at the intermenstrual 
 time, these indicating the rupture of the Graafian follicles.
 
 392 DISEASES OF WOMEN. 
 
 Throughout the entire fruitful, or childbearing period, the devel- 
 opment and rupture of the Graafian follicles, which discharge 
 their ova, are continuously occurring. It may occur independ- 
 ently of menstruation, BUT MENSTRUATION CERTAINLY DEPENDS 
 
 ON THE PHYSIOLOGICAL ACTIVITY OF THE OVARY. 
 
 The GRAAFIAN FOLLICLES begin to swell and enormously 
 increase in size just prior to their rupture. As soon as rupture 
 takes place the ovum thrown out upon the peritoneal aspect of 
 the ovary, is then caught up by the fimbriated extremity of the 
 Fallopian tubes and transmitted by means of the ciliated epithe- 
 lium into the uterus. Some say that the fimbriae are erectile 
 and surround the ovary, while others say that the suction pro- 
 duced by the motion of the cilia, draws the ovum directly into 
 the tube. It is carried directly to the ampulla, or largest part of 
 the tube, at which point impregnation is supposed to take place. 
 
 In a DISEASED CONDITION of the ovaries, OVULATION is pre- 
 vented or interfered with, which results in some form of men- 
 strual disorder. During lactation and pregnancy the process 
 is probably at a standstill, although cases of much sexual irrita- 
 tion following parturition frequently excites activity and brings 
 on ovulation and menstruation. It is also stopped by the re- 
 moval of the entire ovary and usually by removal of the uterus, 
 
 although MENSTRUATION CONTINUES LONGER AFTER REMOVAL OF 
 THE UTERUS THAN OF THE OVARY. IMPREGNATION is most LIKE- 
 LY TO OCCUR, if COITION takes place immediately before or after 
 menstruation. Impregnation may occur at any time, although 
 there are about four days in a month in which it is not likely to 
 take place, these being from the eighteenth to the twenty- 
 second day following the menstrual period. The ovum may stay 
 in the tubes and uterus for some time and still retain the power of be- 
 coming impregnated. The same might be said of the spermatozoa.
 
 PHYSIOLOGICAL PERIODS. 393 
 
 MENSTRUATION is a discharge of blood from the UTERUS 
 and Fallopian tubes, accompanied by the shedding of the super- 
 ficial layers of the mucous membrane, or surface epithelium from 
 it, OCCURRING DURING the period of a woman's sexual activity, 
 from puberty to the menopause, every LUNAR MONTH or twenty- 
 eight days. It is also called menorrhea, catamenia, monthly 
 sickness, turns, periods, sick time, courses or menses. 
 
 Various theories have been set forth to explain this phe- 
 nomenon. The old writers supposed that it was due to a woman's 
 uncleanliness, and menstruation was thought to be an effort on 
 the part of nature to rid herself of noxious elements. Very queer 
 ideas prevailed, such as that a drop of menstrual flow would fade 
 a flower, and that a menstruating woman in a dairy would turn 
 milk sour. Another gives as a cause, a PLETHORIC state of the 
 body, the congested condition being relieved by the menstrual 
 flow. The best theory is that it is a NATURAL process, and one of 
 the functions of the female organs. It prepares a nidus for the re- 
 ception of an impregnated ovum and should be no more of a 
 mystery than ovulation. The part we are most interested in is 
 the disturbances of this function, not the vague theories offered 
 for its explanation. The onset is influenced by race, climate, 
 heredity, environments, food and mode of living. A warm cli- 
 mate, HIGHLY SEASONED food, excitable surroundings, that is 
 SEXUAL EXCITEMENTS, association with the other sex, EROTIC 
 pictures or IMPURE LITERATURE, all tend to bring menstruation 
 on earlier than if these conditions had not existed. Sexual 
 passion is stronger in some than in others, MENSTRUATION AP- 
 PEARING LATE IN THOSE IN WHOM IT IS NOT WELL DEVELOPED. 
 
 In those in whom sexual passion is strong, development is early 
 and the menses appear at an early age. Early menstruation 
 generally means a profuse discharge, disordered menstruation
 
 394 DISEASES OF WOMEN. 
 
 and a late menopause. Late menstruation means scanty and 
 painful menstruation and sterility. At first the menstruation is 
 usually irregular and requires at least a year before regularity 
 is established. The factors which enter into the menstrual func- 
 tion are (1) OVARIAN ACTIVITY, (2) OVARIAN CONGESTION, (3) 
 
 UTERINE CONGESTION, (4) UTERINE CONTRACTION, (5) a MEN- 
 STRUAL FLUID TO BE EXPELLED, and (6) a PASSAGEWAY. ALL 
 MENSTRUAL DISORDERS RESULT FROM DISTURBANCE OF ONE OR 
 
 MORE of these factors. 
 
 MENSTRUAL MOLIMINA include the local and reflex sub- 
 jective symptoms. Just preceding the flow there is a SENSE of 
 WEIGHT and HEAVINESS in the pelvis and limbs. This is the re- 
 sult of the congestion which precedes menstruation. The BREASTS 
 are tender and full, sometimes a slight secretion taking place. 
 The THYROID gland SWELLS and the mucous membrane of the 
 throat becomes congested. It is a well known fact that SINGERS 
 have often CANCELLED ENGAGEMENTS which occurred at the men- 
 strual period, since their voices were affected; either the voice 
 becoming hoarse, husky and changed in quality, or is entirely 
 lost at that time. PIGMENTATION of the skin occurs, the face 
 becoming more sallow with dark rings under the eyes. Herpes 
 or blisters are found on the lips; also they frequently appear on 
 the face, giving it a mottled appearance. The acne of menstrua- 
 tion are perhaps due to some reflex disturbance of the fifth cranial 
 nerve, as it has on it several sympathetic ganglia. 
 
 Nervous changes are noticeable, the patient being changed 
 in disposition ; there is also loss of energy and various other symp- 
 toms of a disturbed nerve supply. HYSTERIA is more prevalent 
 at this time than at any other, and if the patient is subject to 
 epilepsy or hystero-epilepsy the attacks are harder and occur 
 oftener at this time.
 
 PHYSIOLOGICAL PERIODS. 395 
 
 LEUCORRHEA is increased in amount; pruritus is also pres- 
 ent in some cases and gives the patient a great deal of trouble, 
 especially during the latter part of menstruation. There is 
 chronic backache, headache, the heart is subject to palpitation 
 and there is a general feeling of lassitude, tenderness and aching 
 over the entire body. 
 
 THE FLOW consists, for the greater part, of blood which is 
 supplemented by the mucous secretions and epithelial cells. It 
 is ALKALINE in character and has a peculiar odor. In normal 
 cases it is dark in color and free from clots. There should also 
 be absence of pain, but this condition is rarely found. 
 
 The quantity has been estimated at from four to six ounces, 
 but it has quite a physiological variation. This can be estimated 
 by the number of napkins used. If the patient has to change the 
 napkin more than two times per day during the height of the 
 flow, the QUANTITY is excessive. The author has seen cases in 
 which tampons were used to collect or absorb the menstrual flow. 
 Such a practice long continued results in a dilated vagina, fol- 
 lowed by uterine displacement such as retroversion and pro- 
 lapsus. 
 
 The length of the flow is on an average about four days, but 
 may be lessened to two days or increased to as many as six, and 
 yet be normal for that individual. 
 
 The source of the flow is from the mucous membrane lining 
 the uterus and the Fallopian tubes, and a few authors say that 
 some comes even from the ovary. A destructive change occurs 
 in the endometrium which results in its distintegration and the 
 discharge of at least a part. The uterine cavity is soon coated 
 with a new endometrium which furnishes a fresh nidus for the 
 fixation and nutrition of the impregnated ovum. It seems that 
 menstruation is a systemic process, that is one not confined to the
 
 396 DISEASES OF WOMEN. 
 
 pelvic organs, although they are the prime factors. The whole 
 system undergoes a change, the formation and escape of the 
 ovum, its reception into the uterus, and the local symptoms be- 
 ing only a local expression of the general condition. 
 
 CESSATION of the flow occurs on an average at the age of 
 forty-five, yet there are notable exceptions to this rule. LOCAL 
 EXAMINATIONS and TREATMENTS should be avoided, if possible, 
 during the flow, also coition should be prohibited at this time.
 
 GENERAL DISORDERS OF MENSTRUATION. 397 
 
 GENERAL DISORDERS OF MENSTRUATION. 
 
 DISORDERS OF MENSTRUATION. The disorders of men- 
 struation form the most frequent and important of COMPLAINTS 
 of the female. It is rare to find a woman who has no disorder at 
 the menstrual period; in whom the menstrual period is FREE FROM 
 PAIN, of normal amount and length of flow. These disorders do 
 not constitute disease in themselves, but are results or symp- 
 toms of the various uterine displacements and inflammation, 
 and are very important in that they are so common. Habits, 
 mode of dress and fashion, are all combined to make the menstrual 
 period the "SICK TIME" instead of the "well time" as it should be. 
 
 The MENSES may be absent, which is called amenorrhea. 
 The other forms are SCANTY MENSTRUATION; MENORRHAGIA or 
 too profuse flow; PAINFUL MENSTRUATION or DYSMENORRHEA. 
 The flow may come from another part of the body and is then 
 called vicarious menstruation; or it may begin too early, in which 
 case it is called precocious menstruation. Hemorrhage from the 
 uterus at other times than the menstrual period is called met- 
 rorrhagia and does not belong to the disorders of menstruation. 
 There may also be retarded menstruation, or it may become sup- 
 pressed or irregular. 
 
 AMENORRHEA, as the word implies, means absence of a 
 menstrual discharge. It may exist in one of two forms; the pri- 
 mary form, called the EMANSIO MENSIUM; and the secondary form 
 which is called SUPPRESSIO MENSIUM. The primary form is 
 found in cases in which the menses have never appeared although 
 the patient is of the proper age, while the secondary form occurs 
 in cases in which menstruation has once started but has ceased
 
 398 DISEASES OF WOMEN. 
 
 from some cause or other. At certain periods there is a physi- 
 ological amenorrhea, viz., during pregnancy, lactation, before 
 puberty and after the menopause. 
 
 CAUSES. The causes of the primary form, or true amen- 
 orrhea, are the absence of the reproductive organs, and the fail- 
 ure of these organs to develop from their immature state which 
 exists in infancy to the mature state found in maturity. AB- 
 SENCE of the ovaries and tubes; absence or IMPERFECT DEVELOP- 
 MENT of the uterus, or what is called an "INFANTILE UTERUS;" 
 and absence or atresia of the vagina are the usual causes of the 
 primary form. 
 
 An IMPERFORATE HYMEN prevents the external appearance 
 of the menstrual flow and the case is regarded as one of amen- 
 orrhea, but it should be called CONCEALED MENSTRUATION. 
 
 Overwork at, or just preceding the time the menses should 
 be established frequently prevents the development of the pel- 
 vic organs, causing amenorrhea; or it depletes the system, leav- 
 ing, the patient without enough blood to begin the menstrual 
 flow. Diseases, especially of the debilitating class, occurring at 
 this time also prevent menstruation in a similar way. CHANGES 
 IN CLIMATE and environment frequently cause amenorrhea, as 
 is seen in emigrants. 
 
 THE SECONDARY or suppressio mensium form of amenor- 
 rhea is due to a great many causes. This form includes the 
 cases in which the flow has been stopped after puberty has been 
 established, or suppressed after the menses have once begun. 
 
 Since the flow comes principally from the mucous membrane 
 lining the Fallopian tubes and uterus, it follows, that anything 
 causing a lack of blood to these parts, or producing a sudden con- 
 traction of the muscle fibers of the uterus, will cause a cessation 
 of the flow. On account of the ovaries exerting a stimulus over
 
 GENERAL DISORDERS OF MENSTRUATION. 399 
 
 the other pelvic organs, and since they in reality control 
 menstruation, any disease impairing their function will cause 
 disordered menstruation, most commonly amenorrhea. Lesions 
 in the lower dorsal region, affecting the ovaries, may cause 
 amenorrhea. These lesions usually consist of a subluxatecl ver- 
 tebra, or a STIFFENED CONDITION of the spine or a displaced lower 
 rib, which shut off the NERVE FORCE to the ovaries that is neces- 
 sary to the proper performance of their function, which condi- 
 tion results in the absence of ovulation and menstruation. The 
 OVARIES may be inflamed, or some growths may have appeared 
 on them such as a cyst or fibroid tumor. UTERINE DISPLACE- 
 MENTS displace the ovaries and interfere with their function. If 
 this loss of function is complete enough, the influence of the 
 ovaries over the uterus ceases and menstruation stops. 
 
 In the economy of nature there is not enough blood to carry 
 on both the vital functions and menstruation. Since the BLOOD 
 is used to CARRY ON THE VITAL FUNCTIONS, any debilitating dis- 
 ease that impairs its quality or lessens the quantity, if great 
 enough, will cause amenorrhea. In such cases menstruation 
 gradually ceases, that is, the flow becomes more scant each time 
 until it stops completely. In order that there may be normal 
 menstruation two things are necessary: GOOD BLOOD AND UN- 
 IMPAIRED NERVOUS 'ENERGY. Debilitating diseases impair 
 the quality of the blood and VICE VERSA. No better illustration 
 of this can be found than the prevalence of amenorrhea in tuber- 
 cular patients; phthisis being most frequent. It is a POPULAR 
 OPINION that if a girl ceases to menstruate, it is a foregone con- 
 clusion that she is going into consumption. As a rule every one 
 that has tuberculosis has amenorrhea, but it does not necessarily 
 follow that amenorrhea is a symptom of consumption. Anemia, 
 chlorosis, malaria, syphilis and the strumous diathesis are dis-
 
 400 DISEASES OF WOMEN. 
 
 eases and conditions that are accompanied or followed by amenor- 
 rhea. The ACUTE DISEASES also cause at least a temporary cessa- 
 tion of menstruation. This is most marked in the exanthemata. 
 In short, any DISEASE or condition THAT IMPAIRS the QUALITY OF 
 THE BLOOD tends to produce AMENORRHEA, and does in most 
 cases, if the disease becomes chronic. 
 
 OVERWORK, such as hard study, draws the blood to the part 
 that is used most and leaves the pelvic organs anemic, in this way 
 causing amenorrhea. This often occurs in students, usually 
 causing very little discomfort, and SHOULD NOT BE REGARDED AS 
 IMPORTANT, since the menses usually recur as soon as the patient 
 ceases to work. 
 
 Sudden cessation of the flow is due to getting wet, or to other 
 forms of exposure, or it may be due to psychic causes such as the 
 receipt of unexpected news, fright, grief, or extreme joy. The 
 shock to a patient, when menstruating, caused by news of the 
 death of a relative or friend is the most common of these causes. 
 The writer has treated many such cases, in some of which, the 
 melancholic type of insanity developed. 
 
 Any injury or accident which causes marked uterine con- 
 traction will stop the flow. A HARD, STIMULATING treatment 
 applied to the lumbar region will in some cases, stop the normal 
 flow; in others it will bring on the period. Then the question 
 often arises, should we, or can we, stop the normal menses by 
 treatment? In the first place we should not; and in the second 
 place, it can be stopped if the treatment is so hard that it brings 
 on severe uterine contraction. Menorrhagia can be controlled 
 by this kind of treatment, which results in a temporary closing 
 of the os uteri. The more nearly normal the case the less the 
 effect of such treatments. Also there is a TENDENCY on the part 
 of the organism to RESUME NORMAL ACTIVITY, hence the same
 
 GENERAL DISORDERS OF MENSTRUATION. 401 
 
 treatment given for opposite conditions often result in a relief 
 or even cure. Lesions of the pelvic bones shutting off or dimin- 
 ishing the blood supply to the pelvic organs, will cause amenor- 
 rhea if the condition lasts for any length of time. The most 
 common of these lesions is a forward slip of the ilium or back- 
 ward slip of the sacrum. Most lesions of the pelvic bones have a 
 direct effect on the uterus, that is, they cause a passive conges- 
 tion of the uterus. 
 
 ACUTE FLEXION may cause amenorrhea, but more commonly 
 causes dysmenorrhea. Obesity is often stated as a cause of amen- 
 orrhea in young girls, but I think that just the reverse of this 
 condition exists, that is, obesity is the result of cessation of ovarian 
 activity. The same condition takes place after the menopause 
 whether the menopause is natural or acquired. Menstruation 
 usually ceases before obesity occurs, or at least before it has ex- 
 isted very long. In OBESE PEOPLE the generative organs are 
 not so fully developed as in those of a bony make-up. This also 
 holds true in the male, the generative organs as stated above are 
 usually found to be small in fleshy persons. The point is this, 
 the obese are not so strong sexually and the ovaries in their weak- 
 ened condition, do not exert the proper influence over the uterus, 
 hence the disturbed menstruation or amenorrhea. 
 
 SYMPTOMS. The most easily recognizable, and the most 
 important symptom is ABSENCE of the MENSTRUAL FLOW, yet 
 not every case in which there is absence of the flow is one of 
 pathological amenorrhea, although it happens during maturity. 
 If this occurs in a girl who has passed the age at which the flow 
 should have started but did not, it is the primary form. In 
 some the symptoms may be insignificant, but in others there is 
 frequently found headaches in the TOP OF THE HEAD, hot and cold 
 flashes, sense of FULLNESS and PAIN in the ABDOMEN, nervous dis-
 
 402 DISEASES OF WOMEN. 
 
 orders and gastric disturbances. In some, there are all the symp- 
 toms of menstruation except the appearance of the discharge. 
 LOOK AT THE PATIENT. Inspection often readily reveals the 
 true condition. The complexion changes in color, pimples ap- 
 pear on the face, dark rings under the eyes, tenderness of the 
 mammary glands, and there is a dull, achy feeling which is so 
 commonly associated with menstruation. Such symptoms 
 occurring at regular intervals make up the condition called moli- 
 mina. In these cases atresia should be looked for, it being ascer- 
 tained by a digital examination or by the use of a probe or sound. 
 An imperf orate hymen can be diagnosed by inspection. The 
 external genitals are small, and the cervix long and pointed, in- 
 dicating non-development, or the "infantile" type. The ovaries 
 are small and the breasts rudimentary. Patients belonging to 
 this class are anemic, have morbid appetites and are very bash- 
 ful and listless. 
 
 The secondary form is characterized by the stopping of 
 menstruation after its appearance at puberty. The symp- 
 toms are very slight in some cases, while in others they are mark- 
 ed, unless due to debilitating diseases. Not even molimina are 
 found in most cases. These cases are anemic and weak, with 
 loss of strength and ambition; functional heart troubles are fre- 
 quent and the patient has palpitation and dyspnea on the least 
 exertion. DIGESTION and NUTRITION are IMPAIRED, there being 
 anorexia, flatulency, constipation and dyspepsia with its varied 
 symptoms. SLEEP is not good and the patient is unrefreshed by 
 it. Leucorrhea is increased in amount, and in some cases is sup- 
 posed to take the place of the menstrual flow. 
 
 The symptoms of SUPPRESSIO MENSIUM due to exposure or 
 lesions are backache; headache, sense of fullness and weight in 
 the pelvis, tingling and tenderness in the breasts; in short, the
 
 GENERAL DISORDERS OF MENSTRUATION. 403 
 
 patient has all symptoms of the flow without its appearance. 
 These symptoms are exaggerated at the regular time for the menses 
 and cause quite a great deal of discomfort and pain. In such 
 cases the flow may be concealed, that is it may remain in the 
 uterus for several months and then be discharged in the form of 
 black clots and in great quantities. The writer recently had a case 
 of this kind. The patient had missed six monthly periods and 
 there was quite a marked enlargement of the abdomen. In 
 getting a history of the case it was found that she had been in a 
 similar condition several times previously, and with this and the 
 absence of local and reflex symptoms, pregnancy was excluded. 
 On examination the uterus was found enlarged and the os patu- 
 lous. It was suspected that she had retention of the menses, 
 that is a hemometra and possibly physometra, which later the 
 case proved to be. In this case there were the symptoms of 
 anemia, poor nutrition and a general loss of strength. 
 
 Another case of amenorrhea of a different character came 
 to my notice. A young girl had missed two menstrual periods, 
 but few molimina were present. At the fourth menstrual period 
 the uterus seemed to go into labor and after a while LARGE, 
 FLESHY MASSES were expelled. The patient apparently re- 
 covered but the condition returned within a year with similar 
 symptoms. After several months' treatment the case was cured, 
 having been diagnosed as one of uterine mole. Ordinarily, moles 
 result from a diseased condition of the chorion, hence complicate 
 pregnancy, but in this case no history or indication of pregnancy 
 could be obtained although it was undoubtedly a case of uterine 
 mole. After the removal of the fleshy mass, the menses came on 
 in normal manner and continued regular. 
 
 If the menses are SIMPLY delayed there will be HEADACHE, 
 BACKACHE, with a general soreness and uncomfortable feeling.
 
 404 DISEASES OF WOMEN. 
 
 The sudden suppression of the flow from exposure or emotional 
 influences, gives rise to an acute congestion and inflammation of 
 the uterus. The blood is forced back through the Fallopian tubes 
 into the peritoneal cavity, and sets up a peritonitis. The pa- 
 tient has fever, extreme tenderness over the abdomen and in- 
 tense pain. In other cases the symptoms are not so marked, 
 there being only a general feeling of discomfort. 
 
 A sudden strain, slip or fall during menstruation, bringing 
 on a stoppage of the flow, is followed by similar symptoms. The 
 sudden suppression in such cases is due to contraction of the 
 uterus, especially the cervix, which closes the opening of the blood 
 vessels, and occludes the outlet of the uterus. In cases due to 
 overwork, either physical or mental, the amenorrhea WILL COME 
 ON GRADUALLY, with few, if any, SYMPTOMS REFERRED TO THE 
 PELVIC ORGANS. The extra blood is used up in the development 
 of the brain or muscles and little or none is left for menstruation. 
 In such cases the onset is gradual and should cause no alarm. 
 
 DIAGNOSIS. The most IMPORTANT QUESTION pertaining to 
 diagnosis is whether the amenorrhea is PHYSIOLOGICAL AND DUE 
 TO PREGNANCY, either normal or ectopic, or PATHOLOGICAL and 
 the result of disease. If it is physiological and due to pregnancy, 
 the symptoms of pregnancy will be present. The most common 
 of the EARLY INDICATIONS of pregnancy are morning nausea and 
 vomiting, mammary changes in which the primary areolaeform, 
 followed by the secondary areolae, tingling of the breasts 
 with progressive enlargement accompanied in many cases by 
 secretion of milk; ptyalism, flattening followed by enlargement 
 of the abdomen ; softening of the cervix ; change in position of the 
 uterus, it at first becoming anteflexed or anteverted, followed 
 by ascent; Hegar's sign; and the inverted jug shaped appear- 
 ance of the uterus. If these symptoms are present in addi
 
 GENERAL DISORDERS OF MENSTRUATION. 405 
 
 tion to amenorrhea there is probably pregnancy, but a sure diag- 
 nosis can not be made until some of the POSITIVE signs of preg- 
 nancy are obtained. The sure signs of pregnancy are FETAL 
 HEART beat, BALLOTTEMENT and QUICKENING, which signs can 
 not be obtained with certainty before the twentieth week. 
 
 If amenorrhea is found, consider the age of the patient, also 
 her occupation and habits. If above the age of forty, it may be 
 the menopause approaching; or if the patient is a HARD MENTAL 
 WORKER it is the result of using the blood for the development of 
 the brain and leaving little or none for the menstrual function. 
 In getting the history inquire as to the stoppage, whether sudden 
 or after an exposure, fall or strain, or whether it came on grad- 
 ually. Consider the appearance and nourishment of the patient, 
 since it is so frequently associated with anemia and debilitating 
 diseases. 
 
 In cases in which there are no symptoms or signs of mens- 
 truation occurring at stated or regular intervals, physiological 
 amenorrhea exists, and the patient needs no treatment to bring 
 on the flow, SUCH A TREATMENT BEING INJURIOUS RATHER THAN 
 BENEFICIAL. On the other hand in cases of amenorrhea in which 
 there is a single sign or symptom recurring at regular intervals, 
 especially every fourth week, nature is attempting to establish 
 the menstrual flow and such efforts should be aided. Such cases 
 constitute pathological amenorrhea and the establishing of the 
 regular menstrual flow will relieve all symptoms. 
 
 PROGNOSIS. The prognosis depends upon the general 
 health of the patient, mode of onset and length of time the con- 
 dition has existed. In a person otherwise healthy the prognosis 
 is very good. If there is some debilitating disease it is not so 
 good. If congenital, usually it is good unless there is absence of 
 an organ; if due to atresia, stenosis or an imperforate hymen it is
 
 406 DISEASES OF WOMEN. 
 
 favorable since an operation will remove the obstruction. Cases of 
 acute SUPPRESSIO MENSIUM, in which the flow stopped before 
 the third day, CAN BE RELIEVED, and the flow started, if treat- 
 ment is given within twenty-four hours after the stoppage of the 
 flow. I have had cases in which the flow had stopped on the first 
 day, remaining absent five days, and was then brought on by 
 osteopathic treatment, but as a rule it can not be started after it 
 has stopped for so long a time. 
 
 TREATMENT. The treatment of amenorrhea due to an ob- 
 struction such as an atresia or an imperf orate hymen is SURGICAL, 
 an operation being necessary. In cases of non-development, 
 treatment applied to the lesion which causes the trouble by shut- 
 ting off the nerve supply to the organs, is beneficial and sometimes 
 curative. These LESIONS are found from the eighth to the 
 twelfth dorsal vertebra, in the lower lumbar region, sacrum and 
 innominates. Freeing the nerves emanating from the spinal cord 
 in the lower dorsal region, is very helpful. This can be accom- 
 plished by springing the spine, separating the vertebrae if they 
 are grown together making the spine stiff, and by correcting the 
 muscular lesions. I regard SPINAL LESIONS THE MOST IMPORTANT, 
 since they affect ovarian activity and are the true causes of the 
 disease. 
 
 In cases of amenorrhea due to constitutional diseases, do 
 not try to bring on the flow by treatment applied to the pelvic 
 organs. It will be useless, and again it does no good to bring on 
 the menses, even harm being sometimes produced. Nature has 
 tried to preserve all the blood possible by stopping the menstrual 
 flow. The fault is not in the pelvic organs but in the amount and 
 quality of the blood. If there is plenty of good pure blood and 
 amenorreha exists, then the fault may be in the generative or- 
 gans and treatment should be directed to them, otherwise it
 
 GENERAL DISORDERS OF MENSTRUATION. 407 
 
 should *not. Treatment should, as in all cases, be applied to the 
 cause of the trouble. In this case INCREASE the quantity and 
 IMPROVE the quality of the blood by giving the patient plenty of 
 fresh air, outdoor exercise, a sufficient quantity of good nutri- 
 tious food, and osteopathic treatment applied to the blood form- 
 ing organs, such as the liver, spleen, etc. The ribs, if down, 
 should be raised, since neurasthenia, anemia, etc., result from their 
 displacement. In short, correct lesions affecting the abdominal 
 organs. Drug physicians usually prescribe stimulants such as 
 iron, quinine, strychnine and other inorganic poisons, yet Byron 
 Robinson says "We have no known drug which will restore the 
 flow." Do they nourish? No, there is no food in them. Do 
 they increase the amount of nerve force in the body? No, they 
 really weaken it by drawing on the reserve nerve force of the body. 
 Then what do they do? They stimulate, and that is all. WHAT 
 USE has the body for anything introduced into the stomach un- 
 less it counteracts a poison that may be there, or can be absorbed 
 as a food? None, and the poor stomach is made to suffer the 
 effects of strong inorganic drugs not only for the sake of various 
 uterine troubles, but even diseases of more remote organs. Of all 
 the drugs that do so much harm I regard the mineral or inorganic 
 compounds the worst, since no nutrition is found in them and 
 they actually destroy the lining membrane of the stomach. When 
 I have a patient that requires iron I prescribe it, but in a differ- 
 ent form. Fruits, especially those highly colored, such as black- 
 berries and strawberries, abound in iron which is in an organic 
 form and can be absorbed and used to build up the hemoglobin 
 in the blood. Red apples eaten with the peelings on, are espec- 
 ially good, most of the iron being in the peeling. This is the best 
 way to administer drugs, that is, in the form of a natural food. 
 
 IT IS FAR MORE AGREEABLE TO THE PALATE AND BETTER FOR THE
 
 408 DISEASES OF WOMEN. 
 
 STOMACH. In anemic and chlorotic patients suffering from men- 
 orrhea, oxygen, good food and osteopathic treatments are all 
 that are necessary in ordinary cases, which have not reached the 
 incurable stage. The bowels should be regulated, and the other 
 emunctories put in working order. Plenty of good water should 
 be advised, since the body is composed so largely of water. Most 
 people drink too little water, which is the cause of many kidney 
 troubles as well as constipation. 
 
 The treatment to start menstruation, when suddenly stopped 
 by exposure, should be applied to the lower lumbar and sacral 
 regions. The uterus is contracted and by deep work over these 
 regions its muscle fibers can be relaxed. In such cases bony 
 lesions are not always found at first, but often occur later, on 
 account of the constant tension exerted by the contractured 
 muscles. In acute cases, muscular lesions are the most common, 
 while in chronic cases the bony lesions are the cause. By re- 
 moving the muscular lesions which have resulted from exposure, 
 the uterus will relax and the flow start again unless it has been 
 stopped for several days. The muscles are relaxed by removing 
 the irritating factors, and by pressure over the muscle itself. 
 
 SCANTY MENSTRUATION is a relative term used to indi- 
 cate that the amount of menstrual flow HAS BECOME LESS than 
 that to which the individual has been accustomed. In some, 
 the flow is naturally scant, there being only enough to stain the 
 cloth. In such cases it is not pathological. But if the patient 
 has, at her previous periods, passed the normal amount, and 
 afterwards it became diminished, it is PATHOLOGICAL and needs 
 treatment. If the condition is the result of impoverished blood 
 the symptoms will be few or absent. If due to uterine displace- 
 ment or contraction, the patient will suffer pelvic pains, weight 
 in the pelvis, backache or pains in the joints of the lower limbs.
 
 GENERAL DISORDERS OF MENSTRUATION. 409 
 
 A general disturbance of circulation follows, as is evidenced by 
 the COLD HANDS AND FEET. Uterine forms of headache and sense 
 of tightness in the head follow. This is confined to the top of 
 the head or the suboccipital region. 
 
 The causes are the same as for acquired amenorrhea. which 
 has been considered. AMENORRHEA frequently commences in 
 the form of scanty menstruation. Since the causes are very 
 similar to those producing amenorrhea, the treatment will neces- 
 sarily be very similar. INCREASE the amount of blood and im- 
 prove its quality, as anemia is the principal condition which needs 
 correction. After this has been accomplished treatment should 
 be directed to the pelvic organs to better their blood supply. 
 This is done by correcting lesions, both bony and muscular, that 
 obstruct or impair the blood vessels supplying the uterus. If the 
 uterus is in a state of contraction, such as is found in superin- 
 volution, the menses are lessened in amount or are entirely ab- 
 sent. In such cases relax the uterine muscle fibers by an inhibi- 
 tory treatment over the clitoris and the sacral region. If there 
 is a tendency to scanty menstruation or amenorrhea a strong 
 treatment during the menstrual period should be avoided. I 
 have known cases of amenorrhea and retarded menstruation to 
 start from a hard stimulating treatment given during the flow. 
 For this and several other reasons, the physician should know 
 whether or not the patient is in her monthly period when he is 
 treating her if a spinal treatment is necessary. 
 
 MEXORRHAGIA is a condition in which the MENSTRUAL FLOW 
 OCCURS TOO OFTEN or becomes TOO PROFUSE. The increased loss 
 may be due to a shortening of the intermenstrual period, this 
 being the result of a prolonged flow; too frequent menstruation, 
 such as occurs every two weeks; or to an increased amount at 
 each menstrual period. MENORRHAGIA is a term often confound-
 
 410 DISEASES OF WOMEN. 
 
 ed with metrorrhagia, which means non-menstrual uterine hem- 
 orrhage. 
 
 It is a common complaint and gives a great deal of alarm 
 to the patient besides weakening her by excessive loss of blood. 
 It, like scanty menstruation, is a relative term, since what would 
 be MENORRHAGIA FOR ONE would be NORMAL for another. How- 
 ever, if the flow suddenly becomes more profuse than that to 
 which the patient has been accustomed, or if the amount lost is 
 clearly enough to keep the woman in a weakened condition and 
 is a drain upon the system, from which she does not recover dur- 
 ing the intermenstrual period, IT is REGARDED AS MENORRHAGIA. 
 
 CAUSES. Menorrhagia is caused by: FIRST, a relaxed con- 
 dition of the uterus; SECOND, a congested condition of the uterus; 
 or, THIRD, it is due to some disease or condition which lessens the 
 coagulability of the blood. 
 
 Bony lesions tend to affect the tonicity of the uterus by shut- 
 ting off part of the nerve force. This causes the uterine muscle 
 fibers to relax and the uterus to be rilled with blood, hence the 
 menorrhagia. This is one of the important causes, and the one 
 for which the osteopath should at first look. Although the 
 uterus is diseased or displaced, if CONTRACTION takes place HEM- 
 ORRHAGE WILL CEASE, unless the blood is in such a condition that 
 it fails to coagulate. As mentioned above, the middle muscular 
 layer of the uterus is arranged like the figure eight, encircling and 
 twining around and among the blood vessels. IF THESE fibers 
 ARE RELAXED the blood vessels dilate and bleed freely; if con- 
 tracted they act as ligatures which surround the vessels and pre- 
 vent the escape of the blood. This is accomplished partly by 
 the pressure of the contracting muscle fibers, and partly by the 
 formation of an internal clot. 
 
 The MOST COMMON BONY lesion that I have found is a back-
 
 GENERAL DISORDERS OF MENSTRUATION. 411 
 
 ward twist of one innominate bone. The writer has treated 
 cases of menorrhagia caused by lesion of one or both of these 
 bones resulting from an improperly applied treatment given by a 
 student, or even a physician, whereby the innominates were 
 spread apart, or otherwise partially dislocated, resulting in a 
 marked menorrhagia. In one case the patient was placed in the 
 dorsal posture, each ilium was grasped and then forcibly separated, 
 thus producing a lesion of one or both innominates. Judging 
 by this and a great many similar cases, there is no doubt but 
 that innominate lesions do produce menorrhagia. 
 
 The other lesions are; a tilted sacrum, spinal lesions, usually 
 a slight curvature, and a twisting of the entire pelvis. The back- 
 ward slip of one innominate is detected by a change in the direc- 
 tion and height of the crests, and an unnatural prominence of the 
 posterior superior spine on the affected side. TENDERNESS will 
 be found at its articulation and over the upper part of the course 
 of the sciatic nerve. This tenderness in the sciatic nerve is in- 
 dicative of pelvic congestion and is a common symptom in men- 
 orrhagia. The length of the LIMB may not be affected. If a simple 
 backward rotation is found the limb is shortened, but very often 
 this rotation is complicated by a downward slip of the innomi- 
 nate, hence the limb may be lengthened, shortened or not altered 
 in length. The rule is, that if the limb is SLIGHTLY LENGTHENED 
 and of RECENT DATE, it indicates hip trouble; if shortened, a 
 slipped innominate, the most common being a backward rotation. 
 These lesions cause not only a relaxation of the uterine muscle 
 fibers, but also of the muscle fibers of the walls of the blood ves- 
 sels. This produces a distention and congestion and is a gen- 
 eral cause of menorrhagia. Metritis and endometritis are pre- 
 ceded and accompanied by congestion. In fact, all inflammatory 
 conditions are preceded by a congestion. The extra amount of
 
 412 DISEASES OF WOMEN. 
 
 blood escapes at the menstrual period, this being the safety valve 
 by which the congestion is relieved. 
 
 A SUBINVOLUTED uterus is FULL OF BLOOD, enlarged, and is 
 sometimes the seat of inflammation and the cause of menorrhagia. 
 Laceration prevents contraction of the uterus, hence the congest- 
 ed condition. A GRANULAR erosion keeps the parts congested, 
 causing a tendency to profuse menstruation. Since unhealed 
 laceration of the cervix uteri is the most common cause of erosion, 
 it should be looked to as the primary cause of congestion, hence 
 the menorrhagia in such cases. Often there is EVERSION or 
 ECTROPIUM, endometritis, granulations or sensitive papillae which 
 bleed freely on irritation. 
 
 These uterine inflammations also excite GLANDULAR SE- 
 CRETIONS, which form a large part of the DISCHARGE. Inflamma- 
 tion of the mucous surfaces at first diminishes the normal secre- 
 tions, which afterwards become abnormal in quality and increased 
 in amount. This weakens the system almost as much as the 
 loss of blood. 
 
 EXTRA-UTERINE inflammation affecting the ovaries, or 
 oophoritis and salpingitis lead to pelvic congestion and an in- 
 creased flow. If the inflammation impairs the function of the 
 ovaries to any great extent there is a tendency to amenorrhea. 
 
 Uterine displacements cause congestion, resulting in men- 
 orrhagia if the congestion is marked. The most prevalent form 
 of displacement producing menorrhagia is RETROVERSION, al- 
 though it may follow any form if there is much congestion. FI- 
 BROID tumors cause menorrhagia, the degree depending upon the 
 location of the tumor with reference to the uterine wall. A sub- 
 peritoneal fibroid causes the mildest form, the submucous varie- 
 ty the most profuse. Polypi or other fungosities in the uterus 
 almost invariably produce menorrhagia. The profuseness of
 
 GENERAL DISORDERS OF MENSTRUATION. 413 
 
 the flow is by no means in proportion to the size of the intra- 
 uterine growth, since small polypi often act as potently as large 
 tumors. The menorrhagia is in such cases determined by the 
 amount of congestion of the mucous membrane. About the 
 first symptom of the presence of a fibroid tumor or a fungosity 
 is menorrhagia; this is due to the congestion which accompanies 
 the tumor. The hemorrhage does not at first come from the 
 tumor itself but from the congested endometrium. This is also 
 true of malignant tumors appearing before the menopause. In 
 such cases the hemorrhage is bright in color and comes in gushes. 
 The arteries are eroded by the progress of the disease and, since 
 the parts are more congested at the menstrual period than at 
 other times, the HEMORRHAGE is MORE MARKED at that time. 
 This often results in an irregular uterine hemorrhage called 
 metrorrhagia. 
 
 Foreign bodies such as retained pessaries, sponges and tents 
 set up a congestion which is frequently followed by a profuse 
 menstruation. This is also found in an incomplete abortion, or 
 retention of secundines after normal labor, but in such cases the 
 hemorrhage is rather of the form of a metrorrhagia. Organic 
 heart disease produces a passive congestion of the uterus. This 
 is sometimes followed by a profuse menstruation, but this does 
 not necessarily follow. 
 
 Enteroptcsis, or any obstruction which produces a passive 
 congestion will also produce menorrhagia, so that the causes 
 given under congestion of the uterus may be regarded as causes of 
 profuse menstruation. The first two causes mentioned are usually 
 associated. A congested uterus implies one in which the walls 
 are relaxed. 
 
 EXCITEMENT, over-exertion, exposure or a hard spinal treat- 
 ment at,or just prior to, the period, often produces a marked in- 
 crease in the amount of the discharge.
 
 414 DISEASES OF WOMEN. 
 
 Membranous dysmenorrhea is accompanied by flooding. 
 This occurs at the time of, or immediately after expulsion of the 
 membrane, and lasts from a few hours to a day or more. It 
 weakens the patient to a marked extent, as arterial blood is lost 
 in abundance. 
 
 The third cause mentioned is that of some BLOOD disease in 
 which its coagulability is affected. Any debilitating disease in 
 its early stages, on account of the thin condition of the blood, 
 may produce menorrhagia, before the onset of amenorrhea, 
 which occurs after the disease has become chronic and the quantity 
 of blood lessened. A debilitated condition of the whole system is 
 usually accompanied by amenorrhea, but occasionally the op- 
 posite is true. These causes are frequently found in young girls 
 who, at the age of puberty, have grown rapidly, developed too 
 early, or suffer from anemia or some other weakening disease in 
 which the coagulability of the blood is affected. MENSTRUA- 
 TION comes on IRREGULARLY or too frequently, occurring every 
 second or third week. SEXUAL EXCITEMENT, just prior to puber- 
 ty, often deranges the menses, producing copious menstruation, 
 probably on account of the increased activity of the ovaries. 
 Excessive venery frequently provokes ovarian and uterine con- 
 gestion which, after a while, become pathological and are follow- 
 ed by menorrhagia. During lactation the menses sometimes 
 become too free if there is an excessive drain of milk, or if coitus 
 is begun too soon after parturition. In the early stages of phthi- 
 sis the menses are usually profuse, but afterwards diminish as 
 the disease progresses. 
 
 SYMPTOMS. Menorrhagia may occur in three forms: FIRST, 
 a shortening of the intermenstrual period, that is, the flow is pro- 
 longed more than six days; SECOND, an excessive amount of the 
 flow at the period; and THIRD, menstruation occurring every two 
 or three weeks.
 
 GENERAL DISORDERS OF MENSTRUATION. 415 
 
 The local symptoms would be a too profuse, frequent or pro- 
 longed flow. The COLOR of the discharge is usually of a brighter 
 red than normal, indicating an admixture of arterial blood, or it 
 may be venous in character and intermingled with mucous se- 
 cretions. If the loss of blood is very great it produces anemia, 
 pallor of the lips and ears, and a RAPID WEAK PULSE which is 
 easily excited. There may be weakness, faint-ness, a clammy 
 skin, backache and a general neurasthenic condition. If a pa- 
 tient is anemic, weak and tires readily on. the least exertion it 
 indicates a lack of good blood. This may arise from the loss of 
 blood in menorrhagia, or it may be due to a LACK OF BLOOD FOR- 
 MATION and as a consequence in such cases amenorrhea, instead 
 Of menorrhagia is the menstrual disturbance. The color of the 
 blood should be noticed; ARTERIAL HEMORRHAGE FROM ANY PART 
 
 OF THE BODY AT ANY TIME BEING ABNORMAL. Such hemorrhages 
 
 very rapidly weaken the patient. If the discharge is venous in 
 character it is not so alarming. 
 
 DIAGNOSIS. Sometimes it is very hard to tell whether 
 the hemorrhage is the result of menstruation or comes from a 
 tumor, or some other condition such as an abortion, which might 
 cause an irregular discharge of blood. , If the flow is SIMPLY an 
 INCREASE IN AMOUNT OF THE menses the MOLIMINA will be pres- 
 ent and the flow be very near the normal as to color and odor. 
 If the RESULT OF AN ABORTION, the diagnosis is based on the CON- 
 DITION of the mammary glands, there being present the early 
 mammary signs of pregnancy also the secretion of milk coupled 
 with enlargement of the breasts, expulsion of the embryo or fetus 
 with its membranes, no history of previous attacks, and the 
 CHANGE through which the flow passes, it becoming lighter from 
 day to day until it is watery in appearance by the time it ceases. 
 The other early signs and symptoms of pregnancy can be ascer- 
 tained in some cases, this assisting the diagnosis.
 
 416 DISEASES OF WOMEN. 
 
 If the hemorrhage is due to fibroid tumor or cancer, the his- 
 tory of the case, the presence of the tumor, in short, the diagnostic 
 indications of the enlargement are present, therefore the diag- 
 nosis is based on locating the enlargement and noting its char- 
 acter. 
 
 The hemorrhage may be so irregular that the patient cannot 
 tell which is the normal time. If it is the menstrual time, other 
 symptoms of menstruation will be present, such as tenderness in 
 the breast, increased pallor of the complexion, herpes, a more 
 severe headache and backache and a general weakness. 
 
 Before deciding that the case is one of profuse menstruation 
 ascertain the normal amount for that individual and note the 
 secondary anemic symptoms. If the loss of blood, EVEN THOUGH 
 IT BE GREAT, causes none of the reflex symptoms mentioned, 
 it is not pathological and does not need treatment. If molimina 
 accompany the discharge of blood, it is a MENORRHAGIA if the 
 amount is excessive. 
 
 TREATMENT. The treatment should be applied to the 
 cause of the trouble, since menorrhagia is only a symptom. The 
 first thing to do in marked cases is to place the patient in bed 
 with the feet higher than the head and keep her quiet, both 
 PHYSICALLY and MENTALLY. Make the environment as cheer- 
 ful and quiet as possible; do not allow visitors; relieve the patient 
 of any anxiety, for worry and excitement make the condition 
 much harder to cure; keep her in bed, or at least off her feet, so 
 long as the hemorrhage continues, for the erect posture, and es- 
 pecially walking tends to congest the uterus. 
 
 Those cases due to the first mentioned cause, a relaxed con- 
 dition of the uterus, can be cured by producing contraction of 
 the uterus, this being accomplished by CORRECTING THE LESIONS 
 which prevent contraction. If the nerves going to the uterus
 
 GENERAL DISORDERS OF MENSTRUATION. 417 
 
 can be stimulated the uterus will certainly contract. Bony 
 as well as muscular lesions inhibit the nerves going to the uterus, 
 hence their contraction would result in a stimulation of all those 
 nerves. Contraction can be temporarily accomplished by strong 
 manipulation over the lumbar and sacral regions, by deep cir- 
 cular massage over the uterus, or by producing a sudden shock 
 or stimulation by the application of something hot or cold to the 
 abdomen. A slap on the abdomen with the cold hand, or a quick 
 jerk of the hair on the mons Veneris is resorted to in cases of pro- 
 fuse hemorrhage in which an immediate contraction of the uterus 
 is wanted. Sometimes a sudden, but thorough spanking of the 
 buttocks is the best treatment that can be given to get a quick 
 result. The shock, it being unexpected by the patient, produces 
 a contraction of the uterus, that will stop any hemorrhage if the 
 contraction is great enough to ligate the blood vessels. It may 
 not always be policy to give such a treatment, but necessity may 
 demand it. This causes retraction as well as contraction of the 
 uterus. 
 
 ABORTIONS can sometimes be stopped in a similar way, this 
 causing contraction of the cervix. If the uterus can not be made 
 to contract by the above treatment, resort is made to TAMPON- 
 ING the vagina. This often causes a clot to form, after which 
 the hemorrhage ceases. The best tampon to use is the chain 
 tampon, that is several small tampons tied together, enough 
 being used to completely fill the vagina if hemorrhage is 
 marked. If some astringent, such as witch hazel is used there 
 will be a quicker effect. This particular astringent I believe is 
 best since it is soothing and healing, and is especially good if in- 
 flammation is present. Some advise the use of alum, others 
 tannin. Such treatments are only palliative. They do not 
 remove the cause of the trouble, hence do not cure. Local va-
 
 418 DISEASES OF WOMEN. 
 
 ginal treatments are indicated in some cases, particularly in those 
 due to trauma resulting in uterine displacement. More than 
 usual care should be exercised in giving a local treatment while 
 the menses are on, as infection or inflammation may follow. 
 
 In cases of fungosities of the uterus, surgeons advise the use 
 of the sharp uterine curette. The polypi are thus removed and 
 occasionally the patient is benefited. The osteopath is seldom 
 warranted in using such radical measures; relying for a cure on 
 removal of the cause of the disturbance. The polypus, if pro- 
 truding beyond the external os, can and ought to be removed. 
 
 In PARTIAL INVERSION of the uterus, the indentation should 
 be removed by use of a large blunt sound. Such cases occur in 
 patients recovering from parturition, in the very weak and 
 atonic, and often at the menopause. 
 
 In FIBROID TUMORS in which the menorrhagia is marked, 
 little can be done until the growth of the tumor is checked, which 
 often takes several months. In the meantime resort is made to 
 rest in bed and, in bad cases, the use of some astringent. 
 
 If the menorrhagia is the result of congestion and inflamma- 
 tion of the uterus, it should be treated as outlined under the 
 head of metritis and endometritis. If the quality of the blood 
 is impaired treatment should be directed to the blood forming 
 organs. Anything which improves the general health is bene- 
 ficial in the treatment of this form of menorrhagia. For PER- 
 MANENT RELIEF and CURE, REMOVE THE LESIONS, correct the 
 DISPLACEMENTS of the uterus and build up the QUALITY OF THE 
 BLOOD. 
 
 DYSMENORRHEA is a term used to denote pain, preceding, 
 accompanying or following the menstrual discharge, and which 
 is dependent on a disturbance of the menstrual function. This 
 includes pain referred to the pelvic organs which occurs at any
 
 GENERAL DISORDERS OF MENSTRUATION. 419 
 
 time during the menstrual process, dating from the rupture of 
 the Graafian follicle and ending with the completion of the dis- 
 charge. This, like the other menstrual disorders, is ONLY SYMP- 
 TOMATIC, indicating some disease or abnormality of the organs 
 which take part in the menstrual process. 
 
 It is the MOST COMMON of ALL THE MENSTRUAL DISORDERS 
 
 and one that almost ever}- woman experiences either in the chronic 
 or acute form. In fact, pain at the sick time is so common that 
 it is regarded by most women as a NECESSARY ACCOMPANIMENT 
 of menstruation. Theoretically normal menstruation is pain- 
 less, free from clots and causes little inconvenience. 
 
 Dysmenorrhea VARIES IN DEGREE from a FEW PAINS, which 
 do not interfere with the patient's occupation, TO A COMPLETE 
 PROSTRATION which keeps her in bed for some days. In some 
 cases one attack is scarcely over before another is ready to com- 
 mence. Some women are more sensitive to pain than others 
 and exaggerate the pain felt, thus making it hard to estimate the 
 amount of real pain from the description given by the patient. 
 
 PAIN is a sensation which is distressing or agonizing. It 
 is the result of irritation of a sensory nerve or nerves and the con- 
 veyance of the impulse to the sensorium, which refers it back to 
 the periphery of the sensory nerve involved. In this way it is 
 possible for the pain to be referred to a part not diseased, if con- 
 nected with the nerve stimulated, in which it is a case of mistaken 
 identity on the part of the sensorium. Pain is, in reality, in the 
 sensorium. ALL PAINS ARE REFERRED to their SUPPOSED sources, 
 that is, to the point at which the stimulus is supposed to be. 
 In cases of visceral irritation or disease the impulses generated 
 are carried to the spinal cord, thence up the posterior columns 
 to the sensorium, and on account of the LOW DEGREE OF SENSI- 
 BILITY of the viscera, the pain is referred to the cerebrc-spinal
 
 420 DISEASES OF WOMEN. 
 
 nerves in close central connection. This seems to be a wise pro- 
 vision on the part of nature FOR THE PURPOSE OF PROTECTION, 
 
 the BODY BEING GUARDED BY SENSORY NERVES which act as "LIVE 
 
 WIRES," thus warning the organism of a threatened or real dan- 
 ger. Head's law which offers a very good explanation of referred 
 pain is as follows: "When a painful stimulus is applied to a part 
 of low sensibility in close central connection with an area of much 
 greater sensibility, the pain produced is felt in the part of higher 
 sensibility rather than in the part to which the stimulus was ap- 
 plied, unless the stimulus is very great or long continued." To 
 be more explicit or rather to apply it to dysmenorrhea, a pain- 
 ful stimulus applied to the uterus will cause pain in the abdominal 
 
 Wall OVER THE UTERUS. 
 
 This SENSORY IRRITATION is, in most cases of dysmenorrhea, 
 the result of pressure. The pressure may be of various kinds, 
 
 but BLOOD PRESSURE and PRESSURE FROM MUSCULAR CONTRAC- 
 TION, are the most common. This disturbs the nutrition of the 
 nerve or even affects the nerve substance itself. The degree of 
 pain depends upon the degree of pressure and starvation of the 
 nerve. In one case there is sharp pain, in another a dull, radia- 
 ting or labor-like pain, and may be constant or intermittent. It 
 may become intense just before, or just after the flow begins, or 
 it may continue while the flow is on. The seat of the pain may 
 be in the ovary, peritoneum, tubes or uterus, but it may be re- 
 ferred to the back, side, abdomen or limbs. 
 
 VARIETIES of dysmenorrhea depend upon the organs in- 
 volved and how they are affected. It is usually divided into three 
 types: FIRST, the ovarian type, in which the pain precedes the 
 flow and is referred to the ovary; SECOND, the obstructive type; 
 and THIRD, the inflammatory. Usually these types are not dis- 
 tinct but are combined, one running into the other. The ob-
 
 GENERAL DISORDERS OF MENSTRUATION. 42 1 
 
 structive and inflammatory forms most commonly go together. 
 
 From the history of the case, the variety can be ascertained. 
 If the pain precedes the flow from four to eight days it belongs to 
 the OVARIAN type; if it immediately precedes the flow and is re- 
 lieved by the starting of the flow, it is the obstructive form and 
 probably due to a flexion. If the pain continues throughout the 
 period, it is due to INFLAMMATION; if it precedes and also accom- 
 panies the flow it belongs to both the obstructive and inflamma- 
 tory type, such as is found in flexion accompanied by an endo- 
 metritis. 
 
 CAUSES. At each menstrual period the PELVIC ORGANS 
 BECOME CONGESTED. Any diseased condition of these organs 
 tends to increase the congestion, and if the inflammatory stage 
 is reached, painful menstruation follows. The ovaries share in 
 this congestion or they may be separately diseased. It is con- 
 ceded by most writers that the ovaries congest, the Graafian fol- 
 licles swell and rupture and that the ovum escapes a few days 
 prior to the beginning of the menstrual flow. If this process is 
 hindered or impaired it is liable to terminate in pain. In some 
 cases, the rupture of a follicle is hindered by the toughness of 
 the tunic or covering of the ovary. Inflammation of the ovary, 
 called ovaritis, causes pain on account of the markedly increased 
 congestion at that time. The congestion increases the pressure, 
 hence the pain. As soon as the follicle ruptures the congestion 
 is relieved and the pressure decreased. 
 
 Lesions in the lower dorsal region affect the ovary and pro- 
 duce pathological congestion. In chronic cases, these lesions are 
 bony, but in acute cases usually muscular. A case in point 
 might be cited. A young woman, aged sixteen, was taken with 
 a severe pain in the side and back about three days prior to the 
 time at w r hich the flow was expected to begin. On examination
 
 422 DISEASES OF WOMEN. 
 
 the muscles over the lower dorsal region were very much con- 
 tractured. By relaxing these muscles the pain was stopped 
 within a short time. This is the cause of OVARIAN COLIC or 
 "CRAMPS" which is so common. As mentioned before, always 
 look for muscular lesions in acute, and bony lesions in chronic 
 cases. 
 
 Inflammatory conditions of the structures around the ovaries 
 also impair their function and produce this form of dysmenor- 
 rhea. Salpingitis and perimetritis are the most common of these 
 inflammatory conditions around the ovary. The broad liga- 
 ments are frequently found inflamed, resulting in their contrac- 
 tion and from this a disturbance of the ovary. 
 
 The obstructive form of dysmenorrhea is the type attributed 
 to a mechanical obstruction of the uterine canal. Although this 
 is mentioned by some writers as an important cause, I think it 
 is not so important as some other causes, especially the inflamma- 
 tory conditions. Since the blood is able to pass through even a 
 capillary, there must be a very marked and complete obstruc- 
 tion of the uterine canal to prevent the exit of blood. 
 
 Amputation of the cervix, trachelorraphy, or any operation 
 on or injury of the cervix, usually results in the formation of 
 cicatricial tissue, which produces dysmenorrhea. In such cases there 
 is an obstruction caused by the scar tissue plus an interference 
 with the expellant power of the uterus. 
 
 The OBSTRUCTIVE form is rarely found alone, being most fre- 
 quently associated with inflammation, such as endometritis. 
 The flexions, especially anteflexion, are cited as the most typi- 
 cal and most common causes of obstructive dysmenorrhea. The 
 uterine walls collapse at the point of flexion, which condition 
 not only obstructs the uterine canal, but also the BLOOD VES- 
 SELS, so that when the menstrual blood passes into the cavity
 
 GENERAL DISORDERS OF MENSTRUATION. 423 
 
 of the uterus, it meets with this obstacle and stops. On account 
 of this retention there is COAGULATION and the presence of the 
 clots excites the uterine contractions which cause the pain. The 
 pain, how r ever, will be insignificant unless there is a co-existing 
 inflammation. This form is most commonly found in the young 
 but sometimes occurs in multiparae. Stenosis of the os may 
 occur from other causes, such as cicatrization resulting from in- 
 flammation. If this occurs at the internal os, it very readily 
 impinges on the cervical canal causing a narrowing at that point. 
 The tissues in the region of the internal os may thicken and be- 
 come rigid. 
 
 EROSION of the cervix is productive of dysmenorrhea since, 
 in most cases, papillae form around the os and become very sen- 
 sitive, and the pressure caused by the menstrual discharge re- 
 sults in contraction of the circular muscle fibers in the cervix 
 thus CLOSING the os and partly or completely stopping the flow. 
 A very slight exciting cause, such as catching cold, overwork or 
 emotional disturbances, will cause contraction of the cervix. In 
 such cases the cervix, on digital examination, has a soft velvety 
 feeling, although in some cases the papillae can be outlined. On 
 examination with a speculum the tissues around the external os 
 are red in appearance. 
 
 There may be a UTERINE POLYPUS which acts like a ball 
 valve, thereby preventing the exit of the flow. The MUCOUS 
 MEMBRANE becomes congested and in this way produces a nar- 
 rowing of the canal. The circular muscle fibers of the cervix 
 are often found contracted as a result of the irritation, leading to 
 a stenosis of the os. 
 
 Lesions which cause a stimulation of the nerves going to 
 these parts may excite uterine contraction, the most common 
 lesions being those affecting the pelvic bones, principally the in-
 
 424 DISEASES OF WOMEN. 
 
 nominates. Sudden fright or shock causes contraction of this 
 part of the uterus and results in stopping the flow and clots soon 
 form which excite pain upon their expulsion. If the entire uterus 
 relaxes suddenly, the flow will be brought on, this being the 
 case in a sudden fright or excitement. 
 
 The condition of infantile uterus is frequently the cause of 
 dysmennorrhea, in fact painful menstruation is found IN EVERY 
 TYPICAL case of infantile uterus. The CERVIX is SMALL, elongated, 
 softened and conical and the canal running through it is almost 
 obliterated. It relaxes with difficulty and a great deal of pressure 
 from behind is necessary to force anything through the canal. 
 The pressure is produced by uterine contraction, and uterine con- 
 traction, if abnormally hard, is always attended by pain, hence 
 the pain in this form of dysmenorrhea. 
 
 This kind of dysmenorrhea dates from puberty as a rule, 
 and the pain is confined to a FEW DAYS just prior to the menstrual 
 flow, the patient being COMPARATIVELY well during the inter- 
 menstrual period. 
 
 Faulty development is back of nearly all of the obstructive 
 types of dysmenorrhea which occur in nulliparae. Even normal 
 congestion preceding and accompanying menstruation is attend- 
 ed by suffering, since there is a lack of provision for normal 
 expansion. "The organ is imperfect and unripe and, like the 
 nut which casts its hull at maturity, it clings to its decidua most 
 tenaciously before that period." The BLOOD VESSELS SEEM 
 
 SMALL AND INCAPABLE OF CONTAINING THE PROPER AMOUNT OF 
 BLOOD NECESSARY TO NORMAL MENSTRUATION without marked 
 
 increase in intravascular pressure even to the painful degree. 
 The unripe endometrium prevents what there is from es- 
 caping into the uterine cavity, causing pressure and consequent 
 pain. Schultze says: "During the time that the pains of dys-
 
 GENERAL DISORDERS OF MENSTRUATION. 425 
 
 menorrhea are most violent, pains which according to theory, 
 depend on the retention of blood in the cavity of the uterus, the 
 sound may be passed over and over again as far as the fundus 
 without a single drop of blood following its removal, indeed with- 
 out a single drop of blood leaving the uterus for hours or even 
 days afterwards, though the passage is thus proved to be free." 
 The writer has many times confirmed the above statement, thus 
 proving that the BLOOD is IN THE UTERINE WALL, at least NOT 
 IN THE CAVITY. In such cases if the nerves are already hyper- 
 sensitive from a lesion, spinal cord disease or any other cause, 
 the pain is the more marked as a result of the uterine contrac- 
 tions, the uterus going into hard labor in its efforts to expel an 
 imaginary object. 
 
 From this it can be seen how marriage and maternity cure 
 dysmenorrhea due to faulty development. Coitus and preg- 
 nancy develop the uterus, and parturition removes all obstruc- 
 tions. In case of infantile uterus, it generally requires several 
 years of married life to develop it to such a degree that impreg- 
 nation is possible, hence the many cases of sterility for several 
 years after marriage. After parturition, the enclometrium be- 
 comes normal, that is, a new mucous membrane develops which 
 is not thickened, hypersensitive or diseased as was the former. 
 
 The longer congestion continues without hemorrhage taking 
 place, the more violent and distressing the tenesmus becomes. 
 The starting of the flow, if especially free, relieves the intravas- 
 cular pressure and the contractions diminish. In other types of 
 obstructive dysmenorrhea, that is, the forms in which the men- 
 strual flow reaches and accumulates in the uterine cavity, there 
 is some disturbance of the expellant forces of the uterus. Either 
 the fundus does not contract hard enough, or the cervix con- 
 tracts too much; at least polarity is deranged. Polarity is that
 
 426 DISEASES OF WOMEN. 
 
 peculiarity of contraction of the uterus, occurring in labor and 
 menstruation, in which the fundus and cervix act in opposite 
 ways, viz : when the fundus contracts the os dilates. 
 
 The inflammatory causes are the most common and im- 
 portant. As mentioned above, there is a PHYSIOLOGICAL CON- 
 GESTION of all the pelvic organs at the menstrual period which 
 should disappear after menstruation. If there is a weakness or 
 disease the congestion does not entirely disappear. DISPLACE- 
 MENTS of the uterus, lesions along the lower part of the spine and 
 pelvic bones, lack of care at the menstrual period, occupations 
 in which the patient is on her feet a great deal, and mode of dress 
 all tend to increase this congestion, which leads to inflammation, 
 in the form of a metritis or endometritis. Chronic metritis af- 
 fects the entire uterine wall. The muscle fibers are then affected, 
 hence the uterine contraction is necessarily attended by pain. 
 The blood forms into clots and the canal is lessened, both of which 
 are conducive to dysmenorrhea. Congestion precedes and ac- 
 companies the metritis, the uterus is enlarged and the PRESSURE 
 upon the SENSORY nerves is INCREASED. In active congestion 
 there is a painful, throbbing sensation at each beat of the heart. 
 This is the result of increased pressure at each ventricular con- 
 traction. 
 
 Endometritis is probably one of the most common of uterine 
 diseases. It is rare to get a tumor, displacement, or any dis- 
 ease or abnormal condition without some co-existing inflamma- 
 tion of the endometriuni. This mucous membrane thickens 
 and inflames more at the menstrual period than at any other 
 time as a result of the general pelvic congestion. This favors 
 hemorrhage and coagulation of the blood. When uterine con- 
 tractions begin, and they are present in normal menstruation, 
 the uterus is contracting over and around the inflamed surface.
 
 GENERAL DISORDERS OF MENSTRUATION. 
 
 427 
 
 It is, as mentioned before, like gripping something with the hand 
 when the palm is inflamed and sore. It certainly excites pain. 
 The walls of the uterine cavity are tender, congested and inflamed 
 and any contraction produces pain. Now, if there is any ob- 
 struction as from a narrowing of the internal os, flexion or con- 
 traction of the cervix, the pain is increased in proportion to the 
 degree of the obstruction. 
 
 There is a form of painful menstruation, the result of con- 
 gestion and inflammation of the endometrium, called mem- 
 branous dysmenorrhea. It consists of an exfoliation of the endo- 
 metrium and its expulsion EN MASSE at the menstrual period. 
 See Fig. 102. A stripping off and expulsion of this membrane 
 
 FIG. 102. A dysmenorrheal membrane laid open. (Coste.) 
 
 through a small opening is attended by intermittent pains very 
 similar to, and even worse than those of labor. This is a severe 
 and chronic form of dysmenorrhea and one supposed by the med- 
 ical profession to be the hardest type of menstrual disorder to
 
 428 DISEASES OF WOMEN. 
 
 cure, in fact it is regarded as incurable, but osteopathic treat 
 ment seldom fails in such cases. 
 
 Back of these congestive and inflammatory conditions, 
 bony lesions are sought for in chronic cases, and upon their cor- 
 rection depends the cure. Osteopathy corrects these; that is 
 why we cure when other METHODS fail. 
 
 Inflammation of the structures around the uterus is fro 
 quently found as a cause of dysmenorrhea. This leads to ovarian 
 inflammation and salpingitis, and each menstrual period increases 
 the pain on account of the extra congestion at that time. MAL 
 FORMATION, such as atresia, causes retention of the normal flow 
 and finally there is painful distention . 
 
 Some cases are due to constitutional causes, such as GOUT 
 and RHEUMATISM. There may be a neurosis, such as neuras- 
 thenia or hysteria, which makes menstruation painful. Some 
 writers have mentioned a neuralgic type of dysmenorrhea. This 
 is usually found in nulliparae. The os internum is in a state of 
 hyperesthesia, which may be due to a fissured or INFLAMED CON- 
 DITION of the part which, like anal fissure, causes contraction. 
 In some cases there is a cutaneous hyperesthesia of a neuralgic 
 character varying in time, duration and intensity. The nasal 
 type of dysmenorrhea has been noted by the author in a few 
 cases. The mucous membrane lining the nasal fossa is hyper- 
 sensitive. A local anesthetic such as cocaine, will relieve when 
 applied to the nose. 
 
 Sudden stoppage of the flow is followed by pain of a bearing 
 down character. In such cases there is a contraction of the cer- 
 vix which produces a stenosis of the os. This is called the SPAS- 
 MODIC form of dysmenorrhea. The retained blood undergoes 
 coagulation, and the expulsion of the clot is similar to the ex- 
 pulsion of a fetus. In such cases there is CONSIDERABLE PAIN at
 
 GENERAL DISORDERS OF MENSTRUATION. 429 
 
 the NEXT REGULAR period. OVERWORK and EXPOSURE AT ONE 
 
 MENSTRUAL PERIOD INVARIABLY PRODUCE AN INTERFERENCE 
 
 WITH THE NEXT. Delayed menstruation causes increased con- 
 gestion of the uterus, absorption of some of the menstrual flow 
 and the formation of clots, this causing pain when the menses 
 finally appear. 
 
 SYMPTOMS. The symptoms of dysmenorrhea are pains, 
 both local and reflex, of every possible kind as to time, duration, 
 severity and location. The pain preceding menstruation is call- 
 ed ovarian colic or cramp. The congestion of the ovary causes 
 increased pressure on the nerve terminals. 'The patient refers 
 to the pain as in the stomach, but on closer Inquiry and by hav- 
 ing her place her hand on the exact spot it is found to be in the 
 ovary, instead of in the stomach. A great many people either 
 do not know where the stomach is, or they try to mislead you by 
 telling you the pain is in the stomach when in reality it is in the 
 pelvic cavity or abdominal wall in relation with the uterus or 
 ovaries. The pain may be referred to the back, lower dorsal 
 region, or the side. Be careful to diagnose ovarian pain from 
 appendicitis, renal calculi, biliary colic, and from a dislocated rib 
 causing pressure on an intercostal nerve. 
 
 The MUSCLES over the ovary and lower dorsal region will be 
 found contractured. If the pain precedes the flow and is re- 
 lieved by its appearance, it is of the obstructive type. The pain 
 is usually in the form of labor pain, that is intermittent and spas- 
 modic, which in reality it is, since there are uterine contractions. 
 The uterus is trying to overcome an obstruction by increased 
 contraction. In neurotic types the pains increase from time to 
 time. In some there is nausea and vomiting, intense headache 
 and neuralgic pains in various parts of the body. 
 
 The other pelvic viscera are affected. Often there is a limpid
 
 430 DISEASES OF WOMEN. 
 
 condition of the urine; the breasts become swollen and tender; 
 there is an achy, dull, heavy, tired feeling in the lower limbs and 
 back. Nervous prostration follows and the patient is confined 
 to her bed for days or even weeks. The muscles of the back and 
 abdomen are tender, in short, there is a general tenderness over 
 the entire abdomen and the pain persists as long as there is any 
 discharge to be expelled. 
 
 DIAGNOSIS. When I am called to see a case of dysmenor- 
 rhea I usually ask FIRST, when the pain commenced with refer- 
 ence to the beginning of the flow, the character and location of 
 the pain, what caused it and how long it has lasted. If the pain 
 precedes the flow by a few days it indicates ovarian trouble. 
 Likewise the other forms may be partially diagnosed by the time 
 of appearance of the pain. In this way I am able to judge whether 
 the trouble is ovarian or uterine, local or general, acute or chronic, 
 and whether it is due to muscular or bony lesions, a displacement 
 or an inflammatory condition of the uterus. 
 
 Ovarian colic is often closely simulated by a displaced KIH 
 OR RIBS; in fact, this displacement often produces acute ovarian 
 colic, hence the ribs should be examined very carefully for any 
 deviation from the normal, or for tender spots. In biliary cal- 
 culi the other symptoms are present, such as jaundice, pain high 
 up on the right side, constipation, and it is not associated with 
 the menstrual period. RENAL CALCULI can be diagnosed by the 
 location of the pain, it following the course of the ureter and 
 terminating in the vulva or inside the limb, urinary disturbances, 
 such as frequent micturition, hematuria, lessening of the amount 
 of secretion of urine, and tenderness over the kidney and ureter 
 on the affected side. The MEMBRANOUS form of dysmenorrhea 
 is diagnosed from abortion by placing the membranous discharge 
 in clear water. After the blood clots have been washed out, no
 
 GENERAL DISORDERS OF MENSTRUATION. 431 
 
 embryo can be found. The membrane has a shredded appear- 
 ance and floats in the water. Again, in membranous dysmen- 
 orrhea, there are absent the usual signs of pregnancy which are 
 found in pregnant women prior to the second month. 
 
 In diagnosing the different forms of dysmenorrhea keep in 
 mind which factors of menstruation are involved. If the ovaries 
 are diseased their function is altered and pathological congestion 
 results; if there is a cystic degeneration ovulation is affected. 
 If the uterus is inflamed or a flexion exists the expellant forces 
 of the uterus are involved. Hence, by recalling the factors neces- 
 sary to menstruation, namely: OVARIAN CONGESTION (physiol- 
 ogical) and ACTIVITY, UTERINE CONGESTION and CONTRACTION, 
 a fluid to be EXPELLED and an UNOBSTRUCTED PASSAGEWAY, the 
 particular cause can be ascertained. 
 
 TREATMENT. The treatment of dysmenorrhea resolves 
 itself into the removal of the cause producing it, since it, like the 
 other menstrual disorders, is only a symptom and not a disease- 
 If of the ovarian type, correct the lesions that affect the ovarian 
 center. If a lower rib is pressing on an intercostal nerve, and 
 this is a very common cause, correct it and relax the muscles 
 holding it in malposition; the quadratus lumborum being the one 
 commonly at fault. If the rib or vertebral lesion affects the cir- 
 culation of blood to and from the ovarian center, a correction is 
 imperative if a cure is expected. If the ovaries are drawn down 
 by a displaced uterus, correct the displacement. In ovarian 
 colic relax the contractured muscles over the lower dorsal region 
 and give a deep, gentle treatment above, around and over the 
 congested ovary. 
 
 By drawing UP THE INTESTINES, thus releasing the obstruc- 
 tions to the venous return, the colic or neuralgia can be relieved. 
 If a chronic case, the bony lesions must be corrected or the above
 
 432 DISEASES OF WOMEN. 
 
 treatments will give only temporary relief. In conditions of ante- 
 flexion of the uterus producing the obstrucive form, work deeply 
 just above the pubic bone, following the course of the veins. The 
 uterus may be straightened by placing the patient in the dorsal 
 position, having the hips elevated if possible, and giving an up- 
 ward manipulation over the uterus. Nature is trying to straight- 
 en the canal by contraction, and sometimes very little assistance 
 is sufficient to overcome the obstruction. The uterus may 
 straighten of its own accord, but it takes some time and the pro- 
 cess is very painful. A local treatment should not be resorted 
 to unless the efforts to correct it by external treatment have 
 failed; then, if the patient is suffering, a local treatment should 
 be given. 
 
 CONTRACTION of the cervix from stimulation of its nerve 
 supply can be relieved by a treatment applied to the lower dor- 
 sal and lumbar regions and inhibition over the clitoris. The 
 sacro-iliac synchondrosis is the most effective point. I have 
 taken cases of painful contraction of the uterus in which there 
 was extreme cramping and relieved them almost immediately 
 by inhibiting at these points. The INHIBITION is BEST ACCOM- 
 PLISHED by correcting the SLIGHT DEVIATION FOUND IN THIS 
 joint. Pressure against it, with some rotation of the innominate, 
 relieves or releases the disturbed nerve. It requires about 
 fifteen minutes to relieve the cramps in an ordinary case. The 
 muscles at that point are contracted and very tender, and I re- 
 gard the tender spot the point at which treatment should be 
 given. If these cramps are due to a slight delay in menstrua- 
 tion a strong stimulating treatment in the lower lumbar region 
 is usually sufficient to start the flow, thereby relieving the cramp. 
 
 MEMBRANOUS DYSMENORRHEA can be cured by correcting 
 the disturbances of the uterine circulation. This is accomplish
 
 GENERAL DISORDERS OF MENSTRUATION. 433 
 
 ed by correcting the bony lesions which are always found in this 
 form of dysmenorrhea, and by deep treatment over the uterus 
 to relieve the congestion. The writer treated a case in which 
 the entire endometrium was cast off EN MASSE. It was a pear 
 shaped body with two horns corresponding to the entrance of the 
 Fallopian tubes into the uterine cavity. This case was cured by 
 a strong stimulation along the lower part of the back, thereby 
 restoring mobility to the stiffened vertebral articulations. One 
 recent writer suggests that membranous dysmenorrhea is due to 
 a " condition .of widespread venous thrombosis in the vessels of 
 the expelled mucous membrane. This makes its separation by 
 a process of dissecting hemorrhage easy to understand." Grant- 
 ing this to be true, the treatment would not be changed from that 
 outlined above. The vaso-motor centers are impaired by the 
 bony lesions which must be corrected if a cure is obtained. 
 
 The use of the CURETTE is usually resorted to by physicians 
 to remove this diseased endometrium, but as mentioned before. 
 I cannot see how a healthy endometrium will form if THE NUTRI- 
 TION WERE NOT SUFFICIENT in the first place to prevent the dis- 
 eased condition. If the cause of malnutrition were removed, 
 then probably the theory would be right. I have seen a great 
 many cases of this form of dysmenorrhea in which the uterus had 
 been curetted and not one of them was benefited, much less 
 cured. 
 
 In inflammatory forms of dysmenorrhea hot applications 
 and douches are usually advocated, but they give only temporary 
 relief and their constant use weakens and lowers the vitality of 
 the uterus and vaginal walls. Where there is extreme pain they 
 may be resorted to if the case can not be otherwise relieved. 
 Hot drinks are beneficial as they alter the blood and produce 
 changes that are helpful.
 
 434 DISEASES OF WOMEN. 
 
 Stenosis of the cervix is treated by the introduction of a 
 uterine dilator and forcibly dilating the os. I would not like 
 to say that this is never indicated, for it may be in some cases, 
 but these cases are few and far between. If scar tissue has form- 
 ed around the os thus lessening its lumen, the dilator should be 
 used to stretch it. This operation of dilatation is very painful, 
 
 FIG. 103 Uterine dilator 
 
 injures the cervix, gives only temporary relief, and must be per- 
 formed at each menstrual period. Inhibition of the clitoris has 
 a temporary effect in that it relieves the pain for a short while. 
 Treatment applied to the fourth and fifth lumbar and the sacrum 
 has a permanent effect by releasing the nerve force which is in- 
 terfered with usually at these points. Since most cases are due 
 to inflammation, treatment should be applied to correct the 
 causes of the inflammatory condition. These causes are in the 
 main, bony and muscular lesions and uterine displacements, al- 
 though other causes are sometimes found. 
 
 VICARIOUS MENSTRUATION is a form of menstrual dis- 
 order in which the menstrual flow or hemorrhage during men- 
 struation comes from a part other than the uterus. This may 
 entirely take the place of normal menstruation or it may supple- 
 ment it, this being the more common. It is a rare and peculiar 
 condition, and illustrates the fact that menstruation is not a local 
 process, but systemic in character.
 
 GENERAL DISORDERS OF MENSTRUATION . 435 
 
 The HEMORRHAGE may occur from almost any mucous mem- 
 brane of the body, usually from the NOSE, tonsil, throat, gums, 
 stomach, lungs, bowels and breast, or from any superficial 
 ulcer or abrasion of the skin. 
 
 Diarrhea frequently accompanies menstruation. In the vi- 
 carious type, this is sometimes very marked and is of a serous, 
 bloody character. LEUCORRHEA is markedly increased and may 
 entirely take the place of the normal flow. The writer treated 
 a case in which the hemorrhage came from the gums. The face 
 became spotted, teeth ached, head was congested and finally 
 the patient experienced relief only when the menstrual flow was 
 properly established. 
 
 SYMPTOMS. The hemorrhage occurs at the time of the 
 menstrual period and is accompanied by the USUAL SYMPTOMS OF 
 MENSTRUATION. If there is no uterine discharge, molimina are 
 present. There is congestion, pain and swelling of the part from 
 which the flow comes. If the patient has a sore on any part of 
 the body it becomes more congested and painful at the time. I 
 have seen cases in which the inflammation would extend to a 
 radius of an inch from the sore. Such symptoms, recurring at 
 regular intervals of four weeks, make the diagnosis sure. 
 
 TREATMENT. Treatment should be directed to the pelvic 
 organs. Some trouble, such as an inflammation or obstruction 
 to the escape of the discharge, is found there. As a rule, the part 
 from which the hemorrhage comes is weak or diseased and needs 
 strengthening by treatment. A case of HEMATEMESIS recently 
 came under my care, in which the menses would partly be dis- 
 charged in the normal way, then during the latter part of the per- 
 iod the patient would vomit blood, while the discharge from the 
 uterus ceased. In this case the treatment was applied to a dis- 
 placed uterus, also to the stomach which was weak. The real
 
 436 DISEASES OF WOMEN. 
 
 trouble was in the pelvic organs, and by correcting that disorder 
 and at the same time strengthening the stomach, the case was 
 cured. 
 
 PRECOCIOUS MENSTRUATION is a term applied to men- 
 struation occurring before puberty, or else a very early puberty. 
 Instances are on record in which this has occurred at the age of 
 two years. There are few symptoms of menstruation other than 
 the bloody discharge. In some, the genital organs and breasts 
 are partially developed, and a show of sexual passion is present. 
 In most of these cases there is a HEMORRHAGE rather than a MEN- 
 STRUATION, since the usual local and reflex symptoms are absent. 
 The loss of blood weakens the system and should be combatted. 
 Masturbation is frequently found as the real cause and steps 
 should be taken to overcome the habit, if found. 
 
 If it occurs in a girl lacking a few years of normal puberty it 
 indicates an early development of the ovaries, brought on by 
 sexual excitement, evil associates or the reading of immoral lit- 
 erature. In such cases there is marked development of the 
 mammary glands and pelvic organs, while the menstrual periods 
 sre irregular, painful and profuse. 
 
 DELAYED MENSTRUATION is a form of menstrual disor- 
 der in which the menses do not appear at the fourth week but 
 are delayed several days, in some cases nearly the entire month. 
 If delayed two months it would be called amenorrhea. 
 
 It is produced by exposure or injury just before or at the 
 time for the appearance of the flow. A DISPLACED uterus occur- 
 ring at this time often causes it. It produces pelvic uneasiness 
 with pain in the abdomen, back and limbs and is sometimes at- 
 tended by general soreness of the muscles of the entire body. 
 There are molimina and a feeling as if the flow might come on at 
 any time. It may give rise to rheumatic conditions or, in chron-
 
 GENERAL DISORDERS OF MENSTRUATION. 437 
 
 ic cases, the nervous form of rheumatism called rheumatoid 
 arthritis. 
 
 A stimulating treatment in the lumbar and sacral regions 
 coupled with strong percussion of the sacrum, is generally suffi- 
 cient to start the flow, and as soon as it starts the various pains 
 leave. If this is not sufficient sitz baths, hot enemata and va- 
 ginal .douches are helpful as auxiliaries. Sexual intercourse, 
 local treatment, inhibition of the clitoris, all produce uterine con- 
 gestion and dilatation of the os and in many cases are successful 
 in bringing on the flow. 
 
 IRREGULAR MENSTRUATION may be a form of menor- 
 rhagia or it may occur without excessive flow. It dates, in most 
 cases, from puberty, parturition or abortion, and depends upon a 
 disturbed circulation or some interference with the nerve centers 
 controlling menstruation so that the normal stimulus is impaired. 
 Lack of care, exposure and overwork and too severe spinal treat- 
 ments all combine to make menstruation irregular. The inter- 
 menstrual period may be two weeks, then five weeks in length, 
 the patient not knowing when to expect the sick time. The 
 amount varies, being sometimes scant, sometimes profuse. Local 
 pain, as well as the menstrual reflex disturbances, is usually ex- 
 aggerated. 
 
 In the cases that have come under my observation the le- 
 sions have been at the sacro-iliac synchondrosis, there being 
 either a slipped innominate or sacrum. The form which dates 
 from puberty is probably due to interference with the proper 
 development of the uterus or ovaries, more frequently the latter. 
 Displacements and subinvolution following abortion may lead to 
 an irregular menstruation. 
 
 The treatment depends upon the lesions found in the indi-
 
 438 DISEASES OF WOMEN. 
 
 vidual case. If the circulation and nerve supply can be adjusted, 
 the case can be cured. 
 
 PROTRACTED MENSTRUATION. If menstruation is pro- 
 tracted beyond the age of forty-five it is regarded as abnormal if 
 accompanied by other symptoms. In some cases it is the result 
 of continued activity of the ovaries and is not pathological; in 
 others it is the result of some abnormal stimulation of the ovaries 
 or uterus, and is then pathological. It may persist as late as 
 fifty years and impregnation take place, but this is the exception 
 and occurs in few cases. After the age of forty-eight the pres- 
 ence of menstruation is, in many cases, indicative of malignancy, 
 and care should be taken to ascertain the character of the dis- 
 charge, odor and amount. Protracted menstruation is only a 
 symptom and in ordinary cases does not need treatment, but if 
 the hemorrhage is too profuse and there are reflex pains, or if 
 there are symptoms of cancer or other malignant growths, it 
 should be checked if possible.
 
 DISEASES OF THE FALLOPIAN TUBES. 439 
 
 DISEASES OF THE FALLOPIAN TUBES. 
 
 THE FALLOPIAN TUBES. The ANATOMY of the tubes has 
 been considered. Functionally they act as ducts along which 
 the ova and spermatozoa pass, and also serve as receptacles for 
 both the ovum and spermatozoon. They also take part in the 
 menstrual process, the epithelial cells as well as a bloody secre- 
 tion, being cast off. I have seen cases of membranous dys- 
 menorrhea in which there was a cast of the tubes about one-half 
 inch long. It was very fragile, probably a portion had been 
 broken off in its passage. From this it would seem that they are 
 important factors in menstruation. Again, post mortem ex- 
 aminations have been held in women who died during the men- 
 strual flow and blood was found in the tubes, but in these cases 
 it could have been forced back into the tubes from the uterus. 
 Ectopic gestation most frequently occurs in the tubes, the diag- 
 nosis of which will be considered separately. 
 
 DISEASES of the tubes include malformations, occlusion, 
 congestion, displacements, inflammatory conditions and new 
 growths. There may be arrest of development due to some ab- 
 normality of the Mullerian ducts, resulting in an absence of tun- 
 neling or a total absence of one of the ducts. Again, the tubes 
 may be open at the uterine end with a constriction at the middle 
 portion. In such cases there is found an undersized and non- 
 developed ovary on the same side. The malformations give rise 
 to pain at the menstrual time, sterility, or local peritonitis re- 
 sulting from the ova and blood dropping back into the peri- 
 toneal cavity. 
 
 INFLAMMATION of the Fallopian tubes is called salpingi-
 
 440 DISEASES OF WOMEN. 
 
 tis. It is rarely found as a separate disease but is most frequently 
 found in connection with ovaritis or endometritis. The disease is 
 usually unilateral, the left side being attacked more frequently 
 than the right. The mucous membrane swells, this depending 
 in amount on the degree of inflammation and the cilia are ab- 
 sorbed or destroyed, at least their function is perverted. An 
 EXUDATE follows the congestion, which serves to AGGLUTINATE 
 the tube to adjacent structures, principally the peritoneum. This 
 condition continues until ADHESIONS are formed, DRAWING, 
 TWISTING and securely binding the tubes, ovaries and broad lig- 
 aments INTO ONE INFLAMED CONGLOMERATE MASS. Ill marked 
 
 cases pus forms and is forced out into the abdominal cavity; 
 localized peritoneal adhesions form and, if the condition con- 
 tinues, extensive pelvic peritonitis, with its inflammatory exu- 
 dates, follows. In cases due to infection such as gonorrheal in- 
 flammation, pus usually forms. The OSTIUM ABDOMINALE closes 
 and the pus is retained, thus forming a pus sack or pyo-salpinx. 
 
 These tubal inflammations are variously classified but are 
 most commonly divided into acute, chronic and infectious. 
 
 ACUTE SALPINGITIS may be the result of ovaritis or endome- 
 tritis. A sudden stoppage of the menstrual flow, especially from 
 exposure or cold, is followed in most cases by inflammation of the 
 tubes. Labor, and especially abortion, affects the tubes either 
 from trauma or infection during the puerperium. The use of the 
 uterine sound sometimes produces acute salpingitis. 
 
 GONORRHEAL infection may set up an acute inflammatory 
 process, put this is more often chronic. This CAUSE is a very im- 
 portant one in chronic cases. The disease extends by continu- 
 ity of tissue to the Fallopian tubes and ovaries, and when once 
 the gonococci reach the tubes a cure is well nigh impossible. No 
 form of douche will reach the seat of the disease and one has to
 
 DISEASES OF THE FALLOPIAN TUBES. 441 
 
 rely on the germicidal action of the blood to rid the tube of these 
 micro-organisms. I have examined many women who had this 
 type of SALPINGITIS as a result of conjugal relations with a hus- 
 band who had LATENT GONORRHEA. In the early stages there is 
 a vaginitis with altered secretion. This gradually disappears 
 but the patient complains of ovarian trouble, and on examina- 
 tion the uterus, ovaries and tubes are tender. This continues 
 for months and finally the disease becomes localized in the tubes 
 and ovaries and a discharge sets in which is worse during men- 
 struation; the tubes enlarge, remain tender, and the slightest 
 pressure over them is productive of pain. 
 
 Any other condition causing an acute endometritis such as 
 the use of the sound, dilator, tent or medicated douches, will 
 produce salpingitis. If a douche is forcibly introduced into the 
 uterus it is likely that the fluid will be carried through the Fal- 
 lopian tubes into the peritoneal cavity and cause inflammation 
 of the tubes, ovaries and peritoneum. 
 
 In cases of salpingitis the mucous membrane swells, the 
 tubes thicken and an intense pain is located just to the side of the 
 uterus. This pain is acute, lancinating or colicky, or in some 
 cases simply an ache. The patient walks very carefully and 
 avoids shaking or jarring of the body, the least motion of the parts 
 exciting pain. Coitus, coughing, sneezing, or anything moving 
 the tubes either directly or indirectly through a change in the 
 intra-abdominal pressure, will bring on pain. On palpation 
 there is great tenderness over the tubes and, if there is not too 
 much inflammation, the enlarged tubes can be felt through the 
 abdominal wall, in some cases they being almost as large as the 
 finger. There is scanty menstruation unless it has been entirely 
 checked. Dysmenorrhea is also present, it being both of the 
 ovarian and inflammatory type.
 
 442 DISEASES OF WOMEN. 
 
 CHRONIC SALPIXGITIS may follow the acute attack or it 
 may occur independently. Lesions producing chronic pelvic 
 inflammations also produce salpingitis, such lesions being found 
 usually in the lumbar region. The CONTINUED CONGESTION and 
 inflammation tend to produce a constriction or narrowing of the 
 canal and adhesions are often found. The secretions are affected, 
 in many cases pus collects in the tubes producing the condition 
 of pyo-salpinx. This causes an enlargement of the tubes which 
 might be mistaken for an ovarian tumor. 
 
 The symptoms of salpingitis are tenderness over the course 
 of the tubes, and pain on the least jar of the body, such as would 
 result from riding over rough roads or from running or walking 
 rapidly. LEUCORRHEA is found, but this is due rather to the co- 
 existing congestion and inflammation of the uterus than to the 
 salpingitis. PAIN is increased at the menstrual period although 
 there is a constant feeling in the side as if something were pulling 
 down on the ovary. The menses are affected as to amount, there 
 being an' increased flow as the result of congestion. On palpa- 
 tion in the pouch of Douglas, an inflamed mass of tissue can be 
 felt. This enlargement is composed, in most cases, of the tube, 
 ovary, broad ligament and an inflammatory exudate which firm- 
 ly holds the different structures together. 
 
 The latent form of gonorrhea as mentioned above is a very 
 common cause of the chronic form of salpingitis. The patient's 
 
 HEALTH IS UNDERMINED and she Suffers with FEMALE WEAKNESS. 
 
 There is chronic backache and sideache, and the abdomen is very 
 tender. 
 
 Salpingitis is very hard to diagnose from ovarian and uterine 
 disease, but there is little use in so doing as the causes are sim- 
 ilar and treatment about the same. Sometimes tubal disease is 
 mistaken for appendicitis, if the right tube is affected. The
 
 DISEASES OF THE FALLOPIAN TUBES. 443 
 
 diagnosis can be cleared up by noting the position of the mass 
 and by local vaginal examination in which the tube can be reached. 
 The treatment consists of correcting the uterine and ovarian 
 displacement in order to remove the traction which is exerted 
 on the tubes. Also correct bony lesions which interfere with the 
 blood and nerve supply to the parts, or that affect the broad lig- 
 aments. Treatment applied over and around the tubes is some- 
 times beneficial in that it helps to relieve the congestion of these 
 parts. Operations for the removal of the tubes are resorted to 
 by surgeons. In some cases, such as a marked condition of 
 pyo-salpinx, it is indicated, but in a great majority of cases the 
 disease can be cured by osteopathic methods and the operation 
 avoided.
 
 444 DISEASES OF WOMEN. 
 
 OVARIAN DISEASES. 
 
 THE OVARIES are the most important of the PELVIC ORGANS, 
 and exert a predominating influence over the rest of the geni- 
 talia. 
 
 By reference to their anatomy we find that they are oblong 
 bodies located one on either side of the uterus and held in place 
 by the ovarian, infundibulo-pelvic and broad ligaments, being 
 imbedded in the walls of the posterior layer of the last named lig- 
 ament. 
 
 Their development occurs at puberty, at which time they 
 commence to perform their function, that is, ovulation and men- 
 struation begin. Prior to this the ovaries have no function, 
 hence are undeveloped and inactive. Disease, except that re- 
 sulting from an error in development, seldom attacks them be- 
 fore puberty. They sometimes retain their infantile form and 
 size. In such cases they are elongated and extend along, and 
 apparently constitute a part of, the Fallopian tubes. This pecu- 
 liarity is so marked in some cadavers that it is hard to differen- 
 tiate between tubes and ovaries. 
 
 The ovary, like other internal organs, is subject to disease. 
 Primary diseases of these organs are rare, but secondary diseases 
 frequently and readily attack them. The principal diseases are 
 displacement, inflammation and tumors; while in some malfor- 
 mations and non-development are found, in which cases there is 
 sterility and menstrual disorders. 
 
 DISPLACEMENT of the ovary is met with most frequently 
 as the result of a displaced uterus or broad ligament. In some 
 cases it becomes displaced independently of the uterus, as a re-
 
 OVARIAN DISEASES. 445 
 
 suit of stretching and elongation of its ligaments. Such cases 
 are seldom pathological, thus giving rise to few, if any, symp- 
 toms. Since the ovary is imbedded in the posterior wall of the 
 broad ligament, anything which displaces this ligament would 
 
 FIG. 104 Showing prulnpsiiH of ovary and tube into the pouch of Douglas. 
 
 displace the ovary, hence IN ALL UTERINE DISPLACEMENTS the 
 ovary is of necessity displaced, the amount of displacement de- 
 pending upon the degree of the uterine displacement, the amount
 
 446 DISEASES OF WOMEN. 
 
 of relaxation of the ovarian ligaments, and weight of the ovary. 
 The primary form is due to enlargement of the ovary in which 
 the weight is considerably increased. This increase in size may 
 be caused by congestion or a tumor. Excessive venery is re- 
 sponsible for a large, flaccid ovary with weakened, easily stretch- 
 ed ligaments. The repeated congestions from coitus finally lead 
 to a chronic congestion with its hyperplasia, or to inflammation 
 with its cell proliferation. 
 
 In cases of acute retroflexion, the OVARIES are pulled down 
 into the pouch of Douglas where, by rectal or vaginal examina- 
 tion, they can be felt as tender bodies. In such cases DEFECA- 
 TION is PAINFUL as the contents of the bowel in passing through 
 the rectum must impinge on the ovary. In many cases of dis- 
 placed uterus the pain is referred to the side or region of the ovary. 
 There is nausea and even vomiting in some cases, probably due 
 to pressure on or other disturbance of the ovary. Pressure on 
 the testicle in the male, has a similar effect. In such cases of 
 displacement, the ovarian irritation is the real cause of the cramp- 
 ing in the side referred to above. PRESSURE EXERTED DIRECTLY 
 ON THE CONGESTED, displaced ovary, causes a sickening pain like 
 that resulting from pressure on a floating kidney. 
 
 RELAXATION of the ligaments and supports of the ovary also 
 cause its displacement. In pregnancy the ovaries are drawn up- 
 ward and all the structures surrounding them are stretched. If 
 a condition of subinvolution follows parturition, the ovaries are 
 not drawn back into their position but remain in an abnormal 
 position. In such cases the uterus is large and soft, the vaginal 
 walls relaxed, tubes thickened, there is a CHRONIC ACHE in the 
 SIDES and the PAIN is referred to the ovaries. The ovary may 
 sink by its increased weight when it enlarges, as from congestion 
 or the presence of a growth. The left is more frequently pro-
 
 OVARIAN DISEASES. 447 
 
 lapsed than the right, since it is the weaker of the two. Ad- 
 hesions which result from chronic peritonitis often pull the ovary 
 out of place or cause a sense of tightness in that region. 
 
 The symptoms of prolapsed ovary are tenderness and pain 
 over and around the ovary, the pain in some cases being 
 acute, either shooting toward the umbilicus or down the limb. 
 Any motion or jarring of the part increases the pain. In recent 
 cases there are frequently functional derangements of the nerv- 
 ous system. In a thin subject the ovary can be felt by rectal 
 or bimanual examination, it being recognized by its shape, ten- 
 derness and the nauseating sensation from pressure exerted on it. 
 
 It is diagnosed from FECAL IMPACTION by its shape, location 
 and the character of pain resulting from pressure. A SMALL 
 FIBROID is less movable, not tender and is complicated by men- 
 strual disorders, usually menorrhagia. An OVARIAN CYST is 
 larger, fluctuates and rapidly increases in size. 
 
 Many forms of disease of distant organs result from displace- 
 ment of the ovaries, especially if some inflammation complicates 
 the prolapsus. The most common reflex trouble is pain in the 
 iliac fossa in that part supplied by the tenth and eleventh inter- 
 costal nerves. The irritation of the ovary resulting from its dis- 
 placement affects the OVARIAN plexus of nerves, which in turn 
 affects the TENTH, ELEVENTH and TWELFTH segments of the thorac- 
 ic cord. Therefore, impulses arising in the ovarian plexus reach 
 the spinal cord. Applying Head's law we find that the IRRITA- 
 TION or pain is referred to the area supplied by the cerebro-spinal 
 nerves with which the ovarian plexus is connected, viz., the 
 
 TENTH. ELEVENTH and TWELFTH THORACIC nerVCS. The POINT 
 
 of greatest pain is in a small area on a level with and immediately 
 internal to the anterior superior spine of the ilium. The con- 
 stant aching referred to the side, is a common accompaniment of, 
 or sequel to, prolapsus of the ovary with congestion.
 
 448 DISEASES OF WOMEN. 
 
 PAIN in the knee with or without synovitis has occurred in 
 the author's practice. In some cases the knee was very much 
 enlarged from an effusion. Replacement of the uterus and ovary 
 on the affected side, reduced the swelling and relieved the pain. 
 Another case came under my care synovitis of the knee with 
 partial ankylosis of the joint following an attempted abortion in 
 which the ovary was injured. 
 
 The stomach is the most frequently affected of all the vis- 
 cera. Nausea and vomiting occur at irregular intervals, and in- 
 digestion with flatulency is often found as a complication. A 
 displaced uterus, if occurring suddenly, produces intense nausea. 
 This is due in part, if not entirely, to the sudden ovarian displace- 
 ment. 
 
 Hystero-epilepsy constitutes one of the most interesting of 
 the complications of ovarian displacement. In such cases the 
 attack is heralded by the formation of a "KNOT" or "LUMP" 
 which, starting somewhere in the abdominal region, GRADUALLY 
 ASCENDS until it reaches the heart or throat, at which time the 
 patient suddenly loses consciousness. This peculiar movable 
 lump is a fairly reliable indication of ovarian disease, most com- 
 monly a displacement. Hysteria is often manifest by this " lump ' ' 
 in the throat which can not be swallowed. Ovarian displace- 
 ment is commonly found in hysterical patients. 
 
 Dr. Harvey Mayer reported to me a case of epilepsy dating 
 from parturition, which was cured by replacement of a prolasped 
 ovary. The case was one of several years standing and had not 
 been benefited by any form of treatment prior to this. 
 
 TREATMENT consists of first reducing the uterine trouble. 
 If there is subinvolution, endeavor to restore the normal circu- 
 lation by correcting bony lesions, and the uterine displacement, 
 and by abdominal treatments, to lift up the intestines in order to 
 relieve congestion of the uterus.
 
 OVARIAN DISEASES. 449 
 
 Gentle pressure directed AGAINST THE OVARY when the pa- 
 tient is in the knee-chest position, by means of the finger placed 
 in the posterior fornix, will cause it to assume its normal posi- 
 tion unless held down by adhesions or an irreducibly displaced 
 uterus. If adhesions exist they can be broken up by repeated at- 
 tempts at replacement of ovary and uterus. It must be borne 
 in mind that the ovary is a VERY SENSITIVE ORGAN even in its 
 normal condition, and especially so, when displaced and inflamed. 
 This being the case a VERY GENTLE force should be used when re- 
 placing or palpating it. Rest, both physical and sexual, should 
 be demanded, since either one tends to irritate and make worse 
 this condition. 
 
 CONGESTION OF THE OVARY is probably the MOST FRE- 
 QUENT of all ovarian affections. It is rare to find a woman who 
 does not have pain or tenderness in the region of the ovary either 
 constantly or during the menstrual period. This congestion 
 may be primary or secondary. In the young it is usually pri- 
 mary; in multipara, secondary. 
 
 The mind has a great deal to do with the sexual organs, and 
 since the ovaries are the most important of these organs, in that 
 they control and regulate the function of the other pelvic vis- 
 cera, it follows that they are the MOST INFLUENCED by the mind. 
 Stimulation of the higher centers, which are supposed to be in 
 the cerebellum, produces ovarian congestion. This is manifest 
 in the ACHE OF THE OVARY FOLLOWING UNGRATIFIED SEXUAL DE- 
 SIRE, which is the MOST COMMON cause of ovarian congestion in 
 nullipara, and is followed by VARICOSITIES of the veins in the 
 broad ligaments, and usually by ovaritis. If this .occurs repeat- 
 edly, the ovary must of necessity become diseased. An analo- 
 gous condition is found in the male, as is indicated by the aching 
 tender testicle followed by varicocele, if the congestion occurs
 
 450 DISEASES OF WOMEN. 
 
 repeatedly. If there has been sexual excitement the activity 
 of the ovaries is increased by it and whenever this occurs, as is 
 the case when the activity of any organ is increased, congestion 
 follows. Hence it follows that anything which increases sexual 
 desire, whether it comes from immoral associations, impure liter- 
 ature or a lesion which stimulates the pudic nerve or pelvic 
 plexus or nerves, excites ovarian congestion. 
 
 A slipped rib, either by pressing on the structures over the 
 ovaries or interfering with the rami communicantes of the sym- 
 pathetic, often CAUSES OVARIAN CONGESTION. The ganglionic 
 sympathetic chain lies on or NEAR the heads of the ribs, conse- 
 quently a slight displacement of the lower ribs will often disturb 
 the connection existing between the cerebro-spinal and sympa- 
 thetic nervous systems. 
 
 Displacements of the ninth, tenth and eleventh dorsal verte- 
 brae, cause ovarian congestion by affecting the vaso-motor cen- 
 ters of the ovaries. These CENTERS are located in the LOWER 
 THORACIC SEGMENTS of the spinal cord and CONNECT WITH THE 
 OVARIES by way of the white rami, sympathetic ganglia, efferent 
 nerves, which are the lesser and least splanchnics and renal plexus, 
 thence by way of the ovarian plexus to the ovary. These ver- 
 tebral lesions affect (1) the nerves in the corresponding foramina 
 and (2) the blood supply to, and drainage of, these spinal seg- 
 ments, so if these nerve cells are affected in any way, the impulses 
 arising from them would be disturbed. One of the functions of 
 these cells is vaso-motor, hence a disturbance results in an alter- 
 ation of the amount of blood in the ovary. The best explana- 
 tion of the effect on these cells, from the writer's experience, is 
 that the LESIONS IMPAIR the NUTRITION of the cells by AFFECTING 
 
 NORMAL CIRCULATION TO THEM. 
 
 Displacements of the uterus or prolapsus of the ovaries is
 
 OVARIAN DISEASES. 451 
 
 accompanied by congestion and, in most cases, inflammation 
 which may extend from the tubes to the ovaries as a result of 
 chronic congestion of both. 
 
 INTESTINAL PROLAPSUS causes a venous stagnation in the 
 ovaries from pressure on the ovarian veins. These veins are 
 very long and yield to a very slight pressure. 
 
 The symptoms vary with the degree and kind of congestion. 
 If it is active there is a burning, aching, throbbing sensation, 
 acute or lancinating pain, followed by a dull ache in, and tender- 
 ness over the ovary, as the active congestion becomes passive. 
 If a passive congestion, there is a sense of weight and heaviness 
 in the affected side. 
 
 ACUTE OVARITIS is most commonly associated with acute 
 salpingitis, especially the form due to GONORRHEA and ACUTE 
 METRITIS. Sometimes it is found in the puerperal state. Sud- 
 den suppression of the menses causes ovaritis as well as salpin- 
 gitis. In cases of pelvic peritonitis from other causes the inflam- 
 mation extends to the ovary and there sets up an acute inflam- 
 matory condition. 
 
 Most writers on the subject claim that ovaritis is due to 
 microbic infection. Perhaps this is true of the gonorrheal type 
 of ovaritis but I think this not true of the ordinary forms. If 
 microbes are found, that alone does not prove them to be the 
 cause, but it does prove that the tissues are devitalized to such 
 a degree that the organism can not repel the invaders. 
 
 Repeated congestion of the ovary, especially that due to un- 
 gratified sexual excitement, is the most prolific of all causes. The 
 ovary remains congested for days and the patient complains of a 
 constant ache in the side. 
 
 In considering the PATHOLOGY OF ACUTE OVARITIS the changes 
 are similar to those in anv acute inflammation. The ovarv is
 
 452 DISEASES OF WOMEN. 
 
 swollen, softened and the blood vessels engorged. There is often 
 a plastic exudate which covers the ovary, finally resulting in the 
 formation of adhesive bands. This exudate entirely surrounds 
 the ovary and in many cases hides it from view when the pelvic 
 cavity is opened. The tubes and ligaments, particularly the 
 broad ligaments, are usually involved. 
 
 ACUTE OVARITIS may be secondary to mumps, if the patient 
 exercises too soon after an attack. What the connection is be- 
 tween the parotid gland and the ovary the writer will not attempt 
 to explain, but it is well known that there is a close sympathy 
 between the gland and pelvic viscera. This is partly proven by 
 the fact that there is ptyalism in the early stages of pregnancy 
 
 The symptoms can not be differentiated from those of sal- 
 pingitis or a localized peritonitis. There is a burning pain over 
 the ovary, often radiating to the limb on the affected side, which 
 results in a contraction and DRAWING UP of the limbs. The ab- 
 domen is extremely tender to touch, which is indicative of a per- 
 itonitis. On palpation there is usually found A TENDER INFLAMED 
 MASS BACK of and to one side of the uterus. This mass is fixed 
 and consists of the tube, ovary and a pelvic exudate, 
 all of which are bound together, making it hard to outline any 
 one of them. In the early stages the ovary can be outlined, 
 it being exquisitively tender to the touch and much swollen. 
 
 The treatment for temporary relief is to work out the inflam- 
 mation by commencing at the edge of the inflammatory area and 
 gradually working up to the seat of inflammation. Treatment 
 should not be given over the inflamed area at first as there is 
 danger of increasing the irritation. The muscles along the back 
 should be relaxed, since in almost every case they are badly con- 
 tractured. REST should be advised, the patient being allowed 
 on her feet but very little. COITION is painful and should be
 
 OVARIAN DISEASES. 453 
 
 prohibited. In some of my cases I have found a slight twist of 
 the lower dorsal vertebrae, and by correcting this instant relief 
 was obtained. If the ovarian inflammation is a complication of 
 uterine disease, such as acute metritis, the primary or curative 
 treatment should be applied to the uterine disease. Replace- 
 ment, with the starting of the menstrual flow, are the BEST TREAT- 
 MENTS FOR ACUTE METRITIS and will relieve the intense OVARIAN 
 
 CONGESTION and INFLAMMATION. 
 
 CHRONIC OVARITIS, or oophoritis, frequently follows the 
 acute form, especially the primary acute ovaritis resulting from 
 congestion of the ovary. The continued hyperemia at last re- 
 sults in degenerative and inflammatory changes which, after a 
 while, are followed by the chronic form of inflammation. 
 
 Displacements of the ovaries lead to congestion and finally 
 to chronic oophoritis. Chronic uterine inflammation extends to 
 the ovary and there sets up inflammatory changes; chronic sal- 
 pingitis produces a similar condition; latent gonorrhea, by caus- 
 ing a chronic salpingitis, produces the chronic form of oophoritis. 
 Some of the worst cases of ovarian inflammation result from gonor- 
 rheal infection by the husband who had latent gonorrhea. The 
 urethritis was supposed to have been cured but occasionally 
 there would be a slight discharge if the patient strained at stool 
 or in micturition, and especially in the morning. After infecting 
 the wife the disease gradually ascends until it reaches the 
 ovaries. Chronic inflammation follows with a discharge of a 
 
 VERY IRRITATING CHARACTER. In SO me it is SO INTENSELY ACID 
 that it ERODES THE TISSUES WITH WHICH IT COMES IN CONTACT. 
 
 The ovary at first hypertrophies, softens, then the interstitial 
 growth increases from the inflammatory exudate, after which, 
 in favorable cases, it gradually shrinks and becomes very small 
 and hard.
 
 454 DISEASES OF WOMEN. 
 
 The OVARY is sometimes INJURED during childbirth. If 
 prolapsed it is compressed between the fetal head and brim of the 
 pelvis and is bruised if not badly injured. This is followed by 
 inflammation and, in severe cases, pus formation with chronic 
 discharge. 
 
 Lesions along the lower dorsal region, such as any form of 
 curvature, a twisted vertebra or a displaced rib, are the prin- 
 cipal CAUSATIVE FACTORS. If these lesions exist, as weakening 
 or predisposing causes by which the organs lose some of their 
 power of combating disease, then an inflamed or displaced uterus 
 or, in fact, any exciting cause, acts the more readily. 
 
 From a pathological standpoint, the stroma is most involved, 
 but the parenchyma may be affected. There is formation of 
 NEW CONNECTIVE TISSUE, in fact an overgrowth with hypertro- 
 phy of its follicles, from which there often develops retention 
 cysts, thus forming the cystic ovary ; the blood vessels are en- 
 larged and their walls thickened. The WHOLE ovary is EN- 
 LARGED and frequently surrounded by peritoneal adhesions which 
 securely attach it to adjacent structures. 
 
 SYMPTOMS. In chronic ovaritis there is pain and tender- 
 ness in the region of the ovary, the SORE SPOT being JUST ON A 
 LEVEL with the ANTERIOR SUPERIOR spine. This has been ex- 
 plained before as due to the distribution of the tenth and eleventh 
 thoracic nerves which are derived from the same segment that sup- 
 plies the ovary, hence the reflex phenomenon. 
 
 The deep muscles of the lower thoracic region and of the 
 abdomen are often contractured, the patient complaining of a 
 drawing sensation. In the early stages the ovaries may be felt 
 as oblong, tender bodies, deep down in the pelvis. The LYM- 
 PHATIC glands which drain the ovaries are enlarged and tender, 
 and the iliac artery on the same side FREQUENTLY much in-
 
 OVARIAN DISEASES. 455 
 
 creased in size. I have seen cases in which the left iliac artery 
 was TWICE the size of the right, being tense and pulsating very 
 hard. The left ovary was much inflamed in these cases. 
 
 In other cases the pain will be referred to the navel, and in 
 such it is hard to differentiate from abdominal troubles. PAIN 
 is also found in the side and radiating to the back. A slipped rib 
 is nearly always responsible for this kind, and the clothing or a 
 tight belt causes intense pain over the ends of the lower ribs. 
 
 The mammary glands are often tender and swollen, and in 
 some cases there are symptoms of MASTITIS or even malignant 
 diseases. LUMPS or tumors form in the gland and cause a great 
 deal of fear and annoyance. In some the nipples are inverted, 
 that is, instead of an elevation or protuberance there is a depres- 
 sion. THIS is INDICATIVE of OVARIAN DISEASES, usually a chronic 
 inflammation on the same side, but the converse is not neces- 
 sarily true, that is, an inverted nipple is not always found in 
 ovarian disease. Remember that there is close sympathy be- 
 tween the mammary glands and the generative organs, in fact 
 these glands should be classed as appendages of the pelvic organs 
 since their function is dependent on the function of the genera- 
 tive organs. OVARIAN ACTIVITY causes an ENLARGED BREAST 
 and in pregnancy the glands are active in milk secretion. 
 
 MENSTRUAL disorders follow chronic ovaritis; menorrhagia 
 being the most common at first, but as the inflammation pro- 
 gresses the flow becomes scanty, finally resulting in amenorrhea. 
 Dysmenorrhea of the ovarian type is found. An INTERMEN- 
 STRUAL PAIN is occasionally present, recurring regularly, midway 
 between the periods. There is pain on defecation, as in the acute 
 form of inflammation, also in coitus or when the body is suddenly 
 jostled. 
 
 The reflex troubles are many and grave. HYSTERIA is nearly
 
 FIG. 10.> Inverted Nipple (From plioto of author's ease.)
 
 OVARIAN DISEASES. 457 
 
 always accompanied by OVARIAN HYPERESTHESIA; HYSTERO- 
 EPILEPSY is present, the symptoms of which were described in 
 discussion of ovarian displacement, and STERILITY is common if 
 both ovaries are impaired, since the inflammation causes a sus- 
 pension of their function. 
 
 DIAGNOSIS. Sometimes it is hard to differentiate between 
 the different enlargements of the abdomen and pelvis. An en- 
 larged lymphatic gland, if in the region of the ovary, may give 
 rise to symptoms of ovaritis, since there is localized pain and a 
 tumor about the size and shape of the ovary. An impacted 
 bowel is often found but SHOULD NOT BE MISTAKEN FOR ANY- 
 THING ELSE, if care is taken. 
 
 In diagnosing chronic ovaritis keep in mind the above men- 
 tioned symptoms which are peculiar to ovarian disease. Also 
 remember the- symptoms of chronic appendicitis, biliary and 
 renal calculi, constipation, enlarged lymphatic glands and Fal- 
 lopian tube disease. The prognosis is favorable for a cure with- 
 out an operation unless it is of a too chronic form or there has 
 been too much degeneration. Too many lives have been sacri- 
 ficed by experimental operations, THE SURGEON ONLY SUPPOSING 
 THERE WAS SUCH A DISEASE. By osteopathic treatment these 
 operations are avoided and the woman cured without being un- 
 sexed. 
 
 TREATMENT. The PRINCIPAL TREATMENT is to correct 
 the bony lesions causing the disease. The dorsal vertebrae 
 should be lined up, the lower ribs replaced, and uterine displace- 
 ments corrected, as the ovary will very likely be congested and 
 inflamed so long as the uterus is displaced. Abdominal treatment 
 over the ovary, by which the intestines are raised and the broad 
 ligaments straightened is helpful, since it partially, if not com- 
 pletely, removes the obstruction to the return blood flow.
 
 458 DISEASES OF WOMEN. 
 
 Rest is necessary, and the patient must be kept off her feet- 
 as much as possible. Physicians often use electricity, counter- 
 irritants and various drugs, both internally and externally, but 
 all of these do not, and will not, cure, since only the symptoms 
 can be combated by their use. Ovariotomy, as mentioned be- 
 fore, has become quite a fad. A case of supposed ovarian in- 
 flammation, in which there was no disease, was taken to a noted 
 surgeon who, after a careful subjective examination, pronounced 
 it an extreme case of ovaritis and told the patient that unless the 
 ovary was removed at once she would die of "rose" cancer with- 
 in two years. Of course he was mistaken as there was no dis- 
 ease of the ovary, but it illustrates the tendency of some surgeons 
 to cut and try, if an opportunity is given, in almost every case of 
 ovarian or uterine disorder. 
 
 Ovarian abscess follows many cases of inflammation, or, to 
 put it the other way, inflammation always precedes pus formation 
 in the ovary. I look upon pus as decomposed blood, or at least 
 dead blood is necessary to pus formation, the cause of this condi- 
 tion of the blood being lack of motion. Moving blood is live 
 blood; stagnant blood is dead and the elements necessary to pus 
 formation are present. In ovarian abscess the blood has stag- 
 nated in the ovary and undergone decomposition, which steps 
 are preparatory to pus formation. The causes of stagnation of 
 the blood in the ovary have been outlined under causes of con- 
 gestion and inflammation. 
 
 When the pus at first forms it becomes encapsulated; later 
 it burrows into the peritoneal cavity where it becomes circum- 
 scribed but soon sets up a local peritonitis or escapes by burrow- 
 ing into the vagina. Sometimes it escapes BY WAY OP THE TUBES 
 into the uterus, but in either case it is discharged per vaginam. 
 If of slow formation the discharge is thick, greenish yellow or
 
 OVARIAN DISEASES. 459 
 
 brownish from presence of blood, and is worse immediately after 
 the menstrual period. If there is FREE EXIT to the pus, little is 
 absorbed and the toxemia is not marked; but if absorbed, the 
 patient has a CADAVEROUS appearance as a result of the toxemia. 
 In the more marked cases irregular chills come on and the patient 
 gradually grows weaker and more emaciated. 
 
 The diagnosis, in such cases, is based on the character and 
 source of the vaginal discharge. In early stages the usual symp- 
 toms and signs of a deep abscess are present. 
 
 The treatment in mild cases is one directed to restore normal 
 circulation through the diseased ovary, which can be accomplish- 
 ed, if the pathological changes are not too far advanced, by cor- 
 recting vaso-motor disturbances, replacing the uterus and ovaries, 
 and SECURING GOOD DRAINAGE by removing mechanical obstruc- 
 tions to the return flow of the blood. In marked cases that do 
 not yield to osteopathic treatment the diseased ovary should be 
 removed. 
 
 TUMORS of the ovary are usually of the cystic variety, but 
 an occasional solid tumor, such as a dermoid or fibroid, is found. 
 Cysts commonly arise from disturbance of the rupture of the 
 Graafian follicles or of the corpora lutea. The Graafian follicles 
 enlarge and rupture, allowing their contents to escape at each 
 menstrual period. If, from an inflamed condition or any other 
 cause, they do not rupture they continue to swell rapidly and 
 form a cyst. This form is called DROPSY OF THE GRAAFIAN 
 FOLLICLE. The corpus luteum may swell and be filled with a 
 yellow fluid and in this way produce a cyst. The contents of 
 these cysts consist of a clear straw colored fluid which, in chronic 
 cases, sometimes becomes a jelly-like mass surrounded by a thin 
 membrane. 
 
 DERMOID cysts are sometimes found, being somewhat harder
 
 460 DISEASES OF WOMEN. 
 
 and composed of different structures, such as hair, skin, nails 
 and teeth which are derived from the epiblastic layer, and are sup- 
 posed to be the result of invagination of this layer. 
 
 FIBROID tumors of the ovary are occasionally discovered, 
 also cancers, but they are rare. Frequent congestion of the ovary 
 may result in a deposit from which a new growth appears. Tu- 
 mors are found during the period of sexual activity, nullipara 
 being much more liable to disease than multipara, since they do 
 not have the physiological rest enjoyed by the latter during 
 pregnancy and lactation. By the osteopath, displacements of 
 the ribs are associated with ovarian diseases and are regarded as 
 causes of the formation of cysts. The lesions along the lower 
 dorsal region also weaken the ovaries and predispose to disease. 
 
 SYMPTOMS. In cysts of the ovary the tumor is unnoticed 
 until there is some enlargement of the abdomen. If free, so that 
 it can rise in the abdomen, it gives the woman the appearance of 
 being pregnant. If held down so that it can not rise it causes 
 pain in the side, and in the small of the back. The weight of the 
 tumor causes a sense of heaviness and interferes with the pa- 
 tient's gait, giving her the waddling gait of pregnancy. Men- 
 struation is painful and accompanied by an increase in size of the 
 tumor. In some cases there is scanty menstruation or amenor- 
 rhea, making it difficult to diagnose the condition from preg- 
 nancy. The pressure exerted by the tumor gives rise to stomach 
 irritation, edema of the limbs and varicose veins. Hemorrhoids 
 are usually found, resulting from pressure on the hemorrhoidal 
 plexus of veins. Pain is noted from pressure on or stretching 
 of the peritoneum. 
 
 The growth of the cyst is rapid, while that of the fibroid is 
 slow. The general health is at first not affected, but later is 
 gradually impaired and the vitality lowered; there is emaciation,
 
 OVARIAN DISEASES. 
 
 461 
 
 and interference with the functions of the different organs; the 
 face has a careworn, pinched expression, with the lines of the 
 face deepened. To this condition the term "FACIES OVARIANA" 
 
 FIG. 106. Ovarian cyst, front 
 view (From photo of author's 
 
 case.) 
 
 FIG. 107. Ovarian cyst, side 
 view. (From photo of author's 
 case.) 
 
 has been given. The emaciation, shrunken cheeks, hollow eyes, 
 depressed angles of the mouth and distended nostrils make the 
 appearance of the patient characteristic, if in the latter stages of 
 the disease. 
 
 DIAGNOSIS. The diagnosis of an ovarian tumor is based 
 mostly on palpation. In order to do this properly, the abdomen
 
 462 DISEASES OF WOMEN. 
 
 should be bared or the clothing very much loosened. By care- 
 fully laying on both hands the spots of increased resistance can 
 be ascertained. In the early stages the tumor is felt on one side 
 but as it enlarges it pushes inward to the median line and forms 
 a symmetrical enlargement. If the tumor is of a rapid growing 
 variety of cyst it will have an ELASTIC feeling similar to that of a 
 water bag filled with water. 
 
 Fluctuation is an important sign of a cyst. It is obtained 
 by fixing one side of the tumor with one hand, then with the 
 other giving a quick, stroke toward the opposite side. 
 
 Percussion elicits a dull sound over the tumor, while the 
 surrounding tissues give a resonant sound. By local examina- 
 tion the uterus is found pushed out of position and crowded 
 tightly down into the pelvis. The tumor may be felt as a 
 GLOBULAR ELASTIC mass to one side of the uterus. 
 
 By the bimanual method, the size and position of the 
 tumor can be readily ascertained. Pregnency should be kept in 
 mind and its characteristic symptoms looked for, especially if 
 there is amenorrhea. The writer recently saw a case of this 
 kind in which pregnancy was mistaken for a cyst. There was 
 amenorrhea but not the other symptoms of pregnancy. 
 
 Another case came under my notice, in which PREGNANCY 
 complicated a CYSTIC tumor. On abdominal palpation TWO DIS- 
 TINCT bodies could be outlined. Pregnancy was not diagnosed 
 with certainty until fetal heart sounds and quickening were as- 
 certained ; the early indications being obscured by the tumor. 
 The patient carried to term and was delivered of a well developed 
 mature child. In fact, the child was not misshapen in the least, 
 molding not having taken place since the pubic bones were sep- 
 arated by the enormous distention. The patient's waist measure 
 was over sixtv inches, and the lower limbs were black from the
 
 OVARIAN DISEASES. 463 
 
 numerous varicosities. She was operated on four months after 
 delivery and a large multilocular cyst somewhat larger than a 
 water bucket, removed. The patient made an uneventful and 
 complete recovery. 
 
 When there is any doubt as to the disease being a cyst or 
 pregnancy WAIT until the DIAGNOSIS is established before operat- 
 ing, as was done in the above described case. 
 
 Ascites can be diagnosed from a cyst by the character of the 
 enlargement, the presence of some other disease, and the percus- 
 sion note, it being dull at the edges and tympanitic at the center. 
 
 A UTERINE FIBROMA is diagnosed by the consistency of the 
 tumor and the other characteristic symptoms of a fibroid tumor, 
 such as hemorrhage and the character of the pain. 
 
 Distention of the uterus from retention of the menstrual flow 
 may be mistaken for a cyst, but the menstrual disorders, moli- 
 mina and location of the tumor will help to make up the diag- 
 nosis. 
 
 Enlarged lymphatic glands felt through the abdominal wall 
 along either side of the spine, simulate ovarian tumors, but the 
 enlargement is gradual and the growth usually hard. A large 
 tumor is easily recognized but a small one is hard to diagnose. 
 Remember the location of the ovarian cyst, rapidity of growth 
 and the pressure symptoms. Also remember that a prolapsed 
 impacted bowel will form an enlargement, while a displaced rib 
 will give rise to pain in the region of the ovary. 
 
 TREATMENT. A great many cases cured by osteopathic 
 treatment were those in which the former diagnosis was wrong. 
 It is rare to get a true case, but common to get one in which there 
 is some enlargement of the side, simulating ovarian cyst. The 
 bony lesions should be corrected, and whether it is a cyst or not 
 the symptoms abate in most cases.
 
 464 DISEASES OP WOMEN. 
 
 It is not necessary to NAME A DISEASE in order to treat it, 
 although a great many physicians depend upon the name. The 
 osteopath treats and corrects abnormal conditions of the anatomy, 
 REGARDLESS OF NAME or symptoms given it by other physicians. 
 If the case is one of true ovarian cyst, as is best evidenced by ob- 
 taining fluctuation, treat it osteopathically, that is by correct- 
 ing the lesions found. If, after a fair trial, the PATIENT continues 
 to suffer, then, and not until then, should recourse be made to 
 surgery. In addition to correcting bony lesions a loosening up 
 treatment applied to the spinal column, especially the lower dor- 
 sal and lumbar regions, is very helpful. 
 
 The CYST itself can be directly manipulated and relief can 
 be given by treating just above the tumor, lifting up and off the 
 neighboring structures. This abdominal treatment is especially 
 indicated if there are hemorrhoids, varicose veins or any pressure 
 symptoms. 
 
 Solid tumors and dermoid cysts will only be mentioned since 
 they are so rarely met with. Such diseases belong to surgical 
 gynecology and removal is the only rational treatment. For 
 the operation for removal of the ovary or cyst, reference should 
 be made to some work on surgical gynecology. 
 
 Cystic degeneration of the ovary is found in many cases of 
 mal-development, dysmenorrhea or chronic disease of the ovary. 
 The ovary is FLATTENED, ELONGATED, SOFTENED and covered with 
 localized patches of a yellowish color, these patches being areas 
 of degeneration; the uterus is small, soft and usually anteflexed. 
 
 The cause is not well understood. Most of the cases treated 
 by the writer were chronic, the TROUBLE DATING BACK TO PU- 
 BERTY, so it seems that poor development is one of the important 
 causes. DISPLACEMENTS, both uterine and ovarian, were found 
 in some, and in all marked cases, an anterior or flattened condi
 
 OVARIAN DISEASES. 465 
 
 tion of the ninth, tenth, eleventh or twelfth thoracic vertebrae. 
 This condition disturbs the nutrition of the ovary and, if present 
 before puberty, the ovary fails to develop properly, hence the 
 infantile and cystic types. 
 
 The indications of a cystic degeneration of the ovary are, 
 dysmenorrhea of the worst form, usually a MUDDY COMPLEXION 
 with ERUPTIONS and a general RUN DOWN, NERVOUS, MAL-NOUR- 
 ISHED CONDITION. Local examination is often negative, the physi- 
 cian not being able to outline the ovary. In others it can be felt 
 as a flattened, elongated body somewhat tender to the touch. 
 The uterus feels as if it were covered by a thin layer of soft 
 tissue and there is a peculiar slimy condition of the vaginal walls, 
 with leucorrhea present in a very bad form. HEADACHE, INDI- 
 GESTION, NERVOUSNESS and hysteria are common symptoms and 
 the patient presents the appearance of a chronic toxemia with its 
 pasty complexion. 
 
 The treatment consists' of correction of the vertebral lesions. 
 Sometimes this can be done and a cure follows, but in very chronic 
 cases it is difficult and an operation for the removal of the ovaries 
 is indicated, after treatment has been given a fair trial and the 
 patient not benefited. 
 
 OVARIOTOMY is often followed by a PECULIAR DRAWING OR 
 PULLING SENSATION, referred to the lower part of the abdomen, 
 caused by the formation and contraction of the scar tissue. Brandt 
 advises massage in such cases. In some cases treated by the 
 writer, especially those in which hysterectomy had also been per- 
 formed, STRETCHING THE SCAR tissue and BREAKING lip the ad- 
 
 hesions by bimanual manipulation PROVED CURATIVE.
 
 466 DISEASES OF WOMEN. 
 
 REFLEX DISORDERS. 
 
 THE UTERINE and ovarian reflexes constitute one of the 
 most interesting subjects associated with the diseases of women. 
 They are so varied and affect so many organs that I always sus- 
 pect the uterus or ovaries to be in a disordered condition if I have 
 a case in which the symptoms are unusual or peculiar, or which 
 does not yield to the ordinary spinal treatment. The pelvic or- 
 gans may not be at fault, but as a rule, in unusual cases, they are. 
 
 The NERVOUS CONNECTIONS between the ovaries, uterus and 
 vagina, with the splanchnic nerves and with the spinal cord in the 
 lumbar and sacral regions, through the hypogastric and other 
 sympathetic plexuses, ANATOMICALLY explain many of the re- 
 flexes and pains which accompany uterine and ovarian diseases. 
 These reflexes are not confined to the immediate nerves but are 
 found in distant nerves in various parts of the body. The head, 
 eyes, throat or limbs may be affected as frequently as some vis- 
 cus that is near. 
 
 ALL ORGANIC LIFE is RUN by the SYMPATHETIC system. This 
 system, like a chain, is as strong as its weakest point. An ab- 
 normal irritation at one part will give rise to an impulse that will 
 be transmitted over the entire system and if every part is work- 
 ing properly little injury follows, but if one part is weakened, it 
 is not strong enough to stand the increased stimulation or shock 
 and is affected by it. A LACERATED CERVIX, in a STRONG, HEALTHY 
 woman, does not produce ANY APPRECIABLE SECONDARY SYMP- 
 TOMS for several years, but if such an accident occur in a patient 
 already weakened, the effects are immediate. There is nerve 
 loss in both. One can bear it without symptoms, the other can- 
 not.
 
 REFLEX DISORDERS. 467 
 
 Lesions weakening the parts innervated from that region are 
 the predisposing causes of reflexes. If a lesion is found at the 
 fourth dorsal which weakens the heart, ANY UTERINE DISPLACE- 
 MENT would be an exciting cause and would reflexly affect the 
 heart. Loss of nerve force affects the weakest part in a similar 
 way, that is, it increases the weakness of the organ. 
 
 The uterus and ovaries are, or should be, the STRONGEST 
 LINKS of a woman's health in mind and body. Diseases impair- 
 ing them will certainly be followed by general weakness and re- 
 flexes. However, the uterine disease is not always primary but 
 frequently results from a general starved condition of the entire 
 body. 
 
 HEADACHE in the top of the head or in the suboccipital re- 
 gion is characteristic of uterine disease, of which metritis or en- 
 dometritis is the most common. The patient describes the 
 headache as a dull, heavy pain or localized burning sensation in 
 the top of the head. In some cases there is tenderness of the 
 scalp, in others, the pain or ache is internal. If in the neck or 
 suboccipital region there is a dull, constant ache with tendency 
 to retraction of the head. 
 
 Uterine displacements, fibroid tumors, menstrual disorders, 
 INFLAMMATION and CONGESTION of the uterus, all produce this 
 form of headache, the two latter causes being the most common. 
 In some cases, the headache is constant, in others intermittent, 
 while the approach of menstruation or being on the feet more 
 than usual, increases the pain. 
 
 The ACHE in the BACK OF THE NECK and head is partly due 
 to a slipped atlas or axis impinging on the suboccipital nerves, 
 then the exciting cause, or uterine disease, increases the weak- 
 ness and pain. The ache in the TOP OF THE HEAD, is supposed to 
 be due to some disorder of the ganglion ribes, resulting from a
 
 468 DISEASES OF WOMEN. 
 
 disturbance of the lower extremity of the chain, the ganglion im- 
 par. In such cases treatment applied to the neck frequently 
 increases the pain, and even in the most favorable cases only 
 stops it temporarily. 
 
 TREATMENT should be applied to the lower lumbar region, 
 there relaxing contractured muscles and relieving the tension 
 exerted by some displacement which is usually very slight. Many 
 osteopaths have reported to me that INHIBITION AT the SECOND 
 LUMBAR SPINE would relieve the uterine type of headache. Per- 
 sonally, I seldom employ such means, but endeavor if possible 
 to give a corrective, rather than a palliative, treatment. If this 
 does not relieve, recourse should be made to a local treatment 
 which seldom fails to relieve. The writer has cured the worst 
 forms of uterine headaches, after all other methods had failed, 
 by simply LIFTING UP THE UTERUS BY PRESSURE ON THE CER- 
 VIX or completely replacing it if possible. To permanently 
 cure these headaches treatment should be directed to correct 
 the uterine troubles. 
 
 In the male there is a similar headache coming from an en- 
 larged or diseased prostate gland. In such cases the patient 
 complains of a dull, burning pain in the top of the head, tinnitus 
 aurium and loss of memory. On rectal examination, if the pa- 
 tient is above the age of thirty or has indulged in sexual excesses, 
 the PROSTATE gland will be found congested and tender. 
 
 Migraine, also called hemicrania, is a form of headache affect- 
 ing one lateral half of the head and is traceable, in a great many 
 cases, to uterine disease. Endometritis is the most common 
 form producing it. Usually there is an extreme pain and vaso-mo- 
 tor dilatation with increased blood pressure which, in most cases, 
 lasts several days. In some there is a non-developed uterus 
 in others a DISPLACEMENT. The pain is worse near the monthly
 
 REFLEX DISORDERS. 469 
 
 period; also most of these headaches stop at the menopause which 
 indicates that the menstrual function is partly to blame. 
 
 Frontal headaches accompany gastric disturbances, BIL- 
 LIOUSNESS, INDIGESTION and dietetic errors often produce it. 
 The ingestion of ice water often produces pain in the frontal area. 
 McGillicuddy says Lender Brunton finds that "constipation and 
 presumably intestinal irritation cause a diffuse frontal head- 
 ache over the whole brow. When there is not constipation and 
 the condition is one of gastric irritation the pain is either just 
 above the eyes (when it will be relieved by acids) or just at the 
 roots of the hair when it will be relieved by alkalis." This is of 
 interest to us in that it in a measure corroborates our experience. 
 As to the condition of the stomach, or rather as to whether acids 
 or alkalis relieve it, it is important to remember that headache 
 above the eyes suggests an alkaline condition of the stomach; at 
 roots of hair, an acid condition. This condition of the stomach 
 can be changed by treatment applied to the middle thoracic area, 
 the fifth thoracic vertebra being the best place. 
 
 STOMACH DISORDERS are frequently reflex from uterine 
 or ovarian disease or pregnancy. NAUSEA and VOMITING in preg- 
 nancy is a well known example which illustrates the sympathy 
 between the two. However, the better the condition, other things 
 being equal, the less the amount of stomach derangement. If the 
 stomach is in a perfectly normal condition I doubt that nausea and 
 vomiting would occur. If the stomach is weakened by abuse 
 or lesions, coitus, uterine displacements or even the odor of cook- 
 ing food produces nausea or intensifies it when once started. The 
 best immediate treatment for nausea, one that covers a larger 
 per cent of cases than any other, is replacement of the uterus. 
 It has usually settled down in the pelvis, that is, slightly pro- 
 lapsed or the anteflexion is exaggerated.
 
 470 DISEASES OF WOMEN. 
 
 Another illustration of reflex disturbances, principally nausea 
 and vomiting, is found in cases in which the os uteri is rapidly 
 dilated. In some the vomiting is violent and lasts for several 
 hours. During labor the patient often vomits, this being due, 
 possibly, to pressure exerted on the cervix in dilatation of the os. 
 There is a close sympathy between the stomach and the other 
 abdominal and the pelvic organs. Pressure on the kidney, 
 ovary or testicle produces a nauseating effect. 
 
 The NERVE SUPPLY of the uterus is closely connected with 
 that of the other viscera, especially the stomach, through the 
 splanchnic nerves. Since the STOMACH, in this day and age of 
 the world, is ONE OF THE MOST ABUSED ORGANS and one very 
 largely diseased, it follows that it may readily be affected reflexly, 
 the weakest organ being affected first. 
 
 Gastralgia accompanies a recent, or sudden displacement of 
 the uterus, pain being localized over the stomach with con- 
 traction of the abdominal muscles. It is also found in ovarian 
 colic and other forms of painful menstruation. DISTENTIOX of 
 the stomach with gas accompanies the menstrual epoch, and may 
 be so severe that the heart's action is embarrassed by it. "Faint- 
 ness, boulimia and anorexia are frequently the result of uterine 
 or ovarian congestion." Gastralgia frequently occurs at the 
 onset of menstruation. Morbid craving with chlorosis occur at 
 puberty in certain classes of girls. 
 
 In cases of emesis due to a diseased or displaced uterus, or- 
 dinary treatments are seldom effectual, the patient being re- 
 lieved only by replacement of the uterus. An opiate, or even 
 chloroform, has little effect in these cases since the sympathetic 
 system is irritated. 
 
 A DISPLACED OVARY is a common cause of nausea aside from 
 pregnancy. The patient describes it as a "very sick" sensation
 
 REFLEX DISORDERS. 471 
 
 in which she is "sick all over." In SUDDEN UTERINE DISPLACE- 
 MENT, I believe the nausea TO BE DUE more to the OVARIAN dis- 
 turbance which necessarily complicates, than to the uterine. If 
 inflammation is present as a complication of the displacement 
 nausea follows in a large per cent, of chronic as well as acute cases, 
 and is made worse by anything increasing the amount of con- 
 gestion or degree of displacement. 
 
 Chronic dyspepsia is sometimes traceable to uterine disease, 
 in that it affects nutrition, thus weakening all the organs of the 
 body. 
 
 PHARYNGEAL REFLEXES are common. The patient com- 
 plains of something in the throat and is unable, or thinks she is 
 unable to swallow. The writer recalls a case of laceration of the 
 cervix uteri in which the throat was reflexly affected. Con- 
 traction of the throat muscles would begin just as soon as the pa- 
 tient attempted to eat and would prevent her swallowing. In 
 other cases there was found a sore throat or redness of the fauces 
 with no particular inflammation. 
 
 The tonsils frequently enlarge during menstruation and are 
 usually diseased in chronic uterine trouble. This is found par- 
 ticularly in rheumatic cases in which there is retention of the 
 menstrual flow as the cause. Some gynecologists claim that 
 uterine diseases are manifested by changes in the throat so mark- 
 ed and constant that the uterine disturbance can be diagnosed 
 by them. This is true in some cases of catarrhal disease of the 
 uterus. REDNESS of the fauces and chronic disease of the ton- 
 sils are at least suggestive of uterine disease. 
 
 Laryngeal affections from uterine diseases are best repre- 
 sented by a chronic, UNSATISFACTORY, hacking cough which be- 
 comes exaggerated at the menstrual periods and even produces 
 soreness of the abdomen from the frequent straining and con-
 
 472 DISEASES OF WOMEN. 
 
 traction. The voice is sometimes affected and it is a well known 
 fact that singers frequently have to cancel engagements on ac- 
 count of the changes in the voice. 
 
 In VENEREAL diseases, especially syphilis, the throat and 
 voice are affected, the voice becoming harsh and husky. In the 
 above mentioned cases, LESIONS OF THE NECK are predisposing 
 causes and should receive treatment, while the uterine trouble 
 is the exciting cause. 
 
 CEREBRAL NEUROSIS in the form of MELANCHOLIA, mor- 
 bid fears, insomnia and irritability are often met with in cases of 
 chronic uterine disease. Some are due to loss of nerve energy, 
 others to brooding over a supposed or real disease. There is a 
 class of patients who have "UTERUS ON THE BRAIN." They are 
 constantly talking about it, treating it and thinking about it so 
 much that in time probably some disease does arise. These are 
 the kind which are cured by some new remedy, or in which won- 
 derful cures have been made. Another type embraces those 
 who get the "blues," in which there is mental depression, loss 
 of memory, irritability, or perhaps lethargy. In the last men- 
 tioned effect the patient complains of being "no account," al- 
 ways tired and suffers with morbid fears. 
 
 A similar condition is found in the male. Tell a man that 
 he is impotent and he becomes afraid of himself. He imagines 
 that every little pain comes from that, and becomes despondent, 
 melancholic and in a great many cases, suicide is the outcome. 
 The INFLUENCE of the MIND on the pelvic organs is very mark- 
 ed, and in cases in which there is only imaginary disease, SUG- 
 GESTIVE THERAPEUTICS has been used successfully. 
 
 Insanity has followed uterine disease in many cases. Re- 
 cently there was brought to the A. T. Still Infirmary a case of 
 insanity, following TOO FREQUENT CHILDBEARING. The patient
 
 REFLEX DISORDERS. 473 
 
 was treated and cured by correcting AN AXIS lesion, the predis- 
 posing cause. This, with the excessive strain on the nervous 
 system, unbalanced her mind. She had been pregnant four times 
 in three years; in two the fetuses were carried to term, in the 
 other two she aborted. 
 
 The writer was called in consultation in a case of the melan- 
 cholic type of insanity in which there was a history of criminal 
 abortion, the patient thinking that punishment was being sent 
 upon her for her crime. She brooded over her condition and 
 went from bad to worse until she finally died from malnutrition. 
 
 Another case of insanity from ovarian disease came under 
 my notice. The ovaries degenerated and covered with yellowish 
 patches, it being a case of cystic degeneration. Ovariotomy was 
 performed as a last resort but the patient was not benefited. In 
 cases of insanity of these sorts, the cervical lesions are about as 
 important as the pelvic disturbances. 
 
 Insomnia is due to increased activity of the brain, in which 
 there is hyperemia, usually of the active form. Many cases are 
 the direct result of uterine disease of some form, which keeps the 
 sympathetic system in a stimulated condition. Many patients 
 awake at a certain hour and can not go back to sleep. In such 
 cases the heart is stimulated by the irritation to the sympa- 
 thetic gangliated cord, it beats harder and more rapidly, forcing 
 more blood into the brain, thus keeping it active. 
 
 HICCOUGH or " kicking of the diaphragm" is usually 
 hysterical but may follow pelvic irritation. A case of endome- 
 tritis accompanied by hiccough came under my notice, and as 
 soon as the uterine trouble was relieved the hiccoughing ceased, 
 although there was a bony lesion at the fifth cervical which weak- 
 ened the phrenic nerve. The hiccough recurred from time to 
 time until the cervical lesion was corrected.
 
 474 DISEASES OF WOMEN. 
 
 Spasmodic contractions of the diaphragm are in most cases 
 due to uterine displacements. I recently saw a case in which 
 the diaphragm and the abdominal muscles would contract every 
 few seconds, markedly interfering with respiration. After giving the 
 ordinary treatments to reach the phrenic nerve and having failed 
 to stop the spasm, a local EXAMINATION was made and a retro- 
 flexion of the uterus found. As soon as this was corrected the 
 spasms ceased, only to recur when the uterus was again dis- 
 placed. Since the uterus would not stay in the proper position 
 and the spasm recurred as soon as the uterus was displaced, a 
 tampon was placed in the posterior fornix to hold it in place, 
 this entirely relieving the patient. 
 
 In ordinary cases of hiccough inhibition of the phrenic nerve, 
 either at its origin or along its course, holding the breath or drink- 
 ing cold water, is usually sufficient to stop the attack. 
 
 THE CARDIAC reflexes are very common and important, 
 and are indicated by PALPITATION, irregularity, too slow or too 
 rapid pulse, pain in the heart, or " SINKING SPELLS," the patient 
 being unable to breathe while lying down. I have seen cases 
 in which the heart would commence to rapidly palpitate, this 
 lasting for several minutes, then ceasing as suddenly as it began. 
 The most remarkable case of palpitation which ever came under 
 my care was one in which the pulse rate was so rapid that it was 
 impossible to accurately estimate it, these attacks coming on 
 when the uterus became displaced. The uterus was not held 
 firmly in position and a little strain, running, or even standing 
 for a longer period than usual would bring on a displacement. 
 Just as soon as the uterus prolapsed, it seemed to stimulate sym- 
 pathetic nerve force, and in this case the heart was affected in 
 preference to other viscera because of lesions of the fourth and 
 fifth ribs on the left side. The attacks could be checked by re-
 
 REFLEX DISORDERS. 475 
 
 placing the uterus but the patient was not cured until the ribs 
 lesions were corrected. 
 
 Another form of cardiac reflex is the weak or irritable heart 
 which is best represented in patients who have "sinking spells." 
 The patient becomes unconscious, the pulse very weak, in some 
 cases can not be detected, and she has all the symptoms of ap- 
 proaching death. In such cases FIRST RAISE THE RIBS OVER the 
 heart. If that does not relieve give a local treatment, lifting up 
 the uterus, and the effect will be immediate. 
 
 In all those FUNCTIONAL HEART affections, there is some 
 bony lesion, usually at the fourth or fifth dorsal vertebra or cor- 
 responding ribs on the left side which either disturb the innerva- 
 tion or press directly on the heart. 
 
 Pain in the HEART, as in true or false angina pectoris, is the 
 most distressing cardiac reflex, giving the patient the feeling of 
 imminent death. The PAIN is referred to the PRECORDIAL re- 
 gion, back and arm. In the mild forms the attacks last but a 
 few moments and the pain is described as a" stitch" in the region 
 of the heart. Accompanying this is a sense of suffocation, the 
 patient struggles for her breath; the left hand and arm become 
 numb, and in some cases cold and rigid. These symptoms are 
 reflex and are explained by the fact that the same segment of 
 the cord that supplies the arm supplies the heart. The suffocat- 
 ing feeling is due to lessened activity of the heart, which follows 
 an improper oxygenation of the blood. This condition in many 
 cases follows a disturbance of the nerve force to the heart, the 
 result of a bony lesion plus pelvic irritation. 
 
 THE INTESTINAL REFLEXES which accompany uterine 
 diseases are enteralgia, diarrhea and a catarrhal condition in 
 which mucus is discharged. In most cases a mild form of diar- 
 rhea accompanies normal menstruation, as a result of the general
 
 476 DISEASES OF WOMEN. 
 
 congestion of the pelvic organs. This congestion reaches the 
 bowel and from it results a hypersecretion, causing the increased 
 irritation. This also occurs in certain forms of uterine displace- 
 ments, usually backward, pressing on the bowel and stimulating 
 instead of inhibiting it. This is not properly a reflex condition 
 since the organs are in apposition. 
 
 CRAMPING of the intestines occurs in ovarian diseases, es- 
 pecially congestion of the ovary. It seems to be reflected over 
 the entire abdomen with the pain localized around the umbili- 
 cus, in fact patients often say they are suffering with stomach 
 ache. 
 
 Mucous SHREDS or patches are often discharged from the 
 bowels in cases of chronic uterine disease. They have the ap- 
 pearance of a leucorrheal discharge and probably depend upon 
 the same causes that produce leucorrhea. In hystero-epileptic 
 patients, this discharge is greatly increased just prior to the at- 
 tack. 
 
 GLANDULAR REFLEXES are most marked in the mammary 
 glands, they being so intimately associated with the generative 
 organs. During menstruation they become tender and congested, 
 and in pregnancy begin to change in color and size. For a week 
 or more after labor, nursing of the baby brings on after pains by 
 causing uterine contraction. In cases of threatened post partum 
 hemorrhage it is advisable to permit the baby to nurse soon after 
 delivery, encouraging, or probably causing, uterine contraction. 
 
 In most cases of mastitis the TROUBLE LIES IN THE UTERUS. 
 In many cases seen and treated by the writer this could be proven. 
 If the lochial discharge were stopped the mammae became ten- 
 der, but became normal if further uterine trouble were prevented, 
 
 THEIR CONDITION VARYING WITH THE CHANGES IN THE UTERINE 
 CONDITION.
 
 REFLEX DISORDERS. 477 
 
 In polypi of the uterus they are frequently reflexly affected 
 in that they become tender, engorged and in some cases secrete 
 a fluid similar to milk. In many cases of DISPLACEMENT of the 
 UTERUS some ACTIVITY OF THE MAMMARY GLANDS can be noted. 
 The writer has seen cases of uterine displacement in which drops 
 of milk came from the nipple whenever the gland was squeezed. 
 Flexions were most frequently the only causes to which the 
 phenomenon could be attributed. 
 
 At the MENOPAUSE, tingling sensations or even pains occur 
 in the glands. As mentioned under ovarian diseases, inversion 
 of the nipple is indicative of ovarian disease on the same side. 
 Lumps often form in the breast as a result of reflex irritation from 
 uterine disease. In others, a condition of MASTODYNIA is found. 
 In cases of the formation of lumps the physician usually diag- 
 noses the case as one of cancer of the breast and advises removal. 
 
 In some the breasts atrophy, in others they hypertrophy. 
 As stated before, the size of the breast is determined by the degree 
 of activity of the sexual organs, the ovaries having the most to 
 do with it. 
 
 The thyroid gland, the function of which is yet unknown, 
 enlarges at the menstrual period and during pregnancy. Cer- 
 tain forms of goitre are, I think, due in many cases to uterine 
 diseases as an exciting cause while the predisposing cause is a 
 displaced first rib, or a lesion of the lower cervical vertebrae or 
 clavicle. It is exceedingly rare to find a case of true goitre in the 
 male, and this alone is suggestive of some close connection be- 
 tween the gland and the sexual organs. 
 
 " Whenever there is a persistent irritation involving the 
 uterine muscles, it will cause a persistent swelling of the thyroid." 
 The globus hystericus is more common at the menstrual time. 
 This is the result of the enlargement thus causing a NARROWING
 
 478 DISEASES OF WOMEN. 
 
 OF THE canal, which produces the sensation of a knot in the throat. 
 Reed says "women with goitre generally suffer with menorrha- 
 gia and metrorrhagia ; extirpation of the thyroid is followed by 
 general atrophy. Myxedema in women is generally associated 
 with amenorrhea. In Cretins, there is a diminution and often 
 an entire loss of sexual power. Menstrual symptoms are among 
 the foremost symptoms of exophthalmic goitre." 
 
 Ptyalism, or increased secretion of saliva, is one of the early 
 symptoms of pregnancy and is also found associated with men- 
 struation. Often the parotid glands enlarge at this time. The 
 writer had a case in w r hich the salivary glands enlarged soon after 
 the patient gave birth to a child. At a second pregnancy the 
 swelling disappeared but immediately after confinement they be- 
 came enlarged a second time. 
 
 As mentioned before, the tonsils are sometimes reflexly dis- 
 eased as a result of uterine displacement. Women subject to 
 tonsillitis usually have ovarian disease. In some cases the ton- 
 sils become hard and tender at periodic intervals corresponding 
 to the menstrual periods. Parotitis often descends to the ovary, 
 producing a severe ovaritis. 
 
 The sweat glands are also frequently diseased as a result of 
 uterine trouble, but if inactive, are more often the cause of 
 uterine disturbances. Excessive perspiration is found in some 
 patients. In others the odor is very marked and offensive, es- 
 pecially that from the AXILLARY GLANDS. In many cases a local- 
 ized perspiration takes place, sometimes a lateral half of the face 
 being bathed in sweat while the opposite side is perfectly dry. 
 Such a condition is called HEMIDROSIS. Cervical lesions were 
 present in all such cases treated by the writer. Rheumatism and 
 RHEUMATOID ARTHRITIS follow the RETENTION of the menstrual 
 flow if the sweat glands are inactive. The skin is harsh and dry
 
 REFLEX DISORDERS. 479 
 
 and does not excrete the poisonous elements arising from re- 
 tention of the menses, hence they remain in the blood and give 
 rise to symptoms closely resembling rheumatism. 
 
 HYPERESTHESIA accompanies pelvic disease in many 
 cases. In these cases the spine is irritable and the least cutane- 
 ous stimulation produces a marked contraction or even a spasm 
 of the muscles of the body. A light touch is productive of a 
 greater reflex than quite a heavy presssure. In some there are 
 shooting pains in different parts of the body, especially in the in- 
 tercostal nerves, which come and go, remaining only an instant. 
 In others the PAIN is REFERRED only to the spinal column and 
 the least irritation excites rigid contractions. In most of the 
 cases I have examined uterine trouble was found. A DISPLACE- 
 MENT, usually backward with a metritis, is the most common 
 cause producing it. These troubles can be traced back to a hard 
 fall or sudden jar of the body which produced the uterine dis- 
 placement, this in turn affecting the ovaries and causing hyper- 
 esthesia of them. 
 
 In some cases there is a CONGESTION of the SPINAL CORD and 
 MENINGES, which keeps the nerve cells and nerves, especially the 
 sensory nerves, in a state of irritation. The supraspinous lig- 
 aments are softened and thickened as a result of the increased 
 vascularity and seem to be readily compressed on palpation, this 
 giving a sort of crepitus-like feeling or sensation. Spinal irrita- 
 tion is a very common accompaniment of hysteria, the tender 
 spots often changing from time to time and from place to place. 
 
 The treatment in such cases must be a very gentle and mild 
 spinal treatment by which the hyperesthesia is gradually work- 
 ed out as the nerves become better nourished and the circula- 
 tion improves. Bony lesions along the spinal column indicate the 
 points at which the irritation is greatest. These should be care-
 
 480 DISEASES OF WOMEN. 
 
 fully treated and finally corrected, this being a preliminary step 
 to the correction of the uterine disease or displacement. A HARD 
 SPINAL TREATMENT in such cases invariably BRINGS ON THE MEN- 
 STRUAL FLOW. Local, treatment should be given occasionally 
 if there is a displacement, if the uterus does not remain in posi- 
 tion after it has once been replaced. The inflammation should 
 be treated and the pelvic circulation regulated. 
 
 The prognosis is unfavorable for a rapid cure since it takes 
 time to overcome the general run-down condition of the system, 
 but in time a majority of these cases can be cured. Patients 
 have come to the A. T. Still Infirmary that had been given 
 all the ordinary treatments for this condition, without any help. 
 By correcting the bony lesions interfering with the pelvic circu- 
 lation, these cases have been cured, which goes to prove that the 
 bony lesions were the real cause of the hyperesthesia. 
 
 This condition frequently follows typhoid fever as a result 
 of the severe muscular contractions which have pulled the ribs 
 and vertebrae slightly out of place. Some cases are due to an 
 interference with the CIRCULATION OF THE SPINAL CORD, and in 
 these as in most other cases, the spinal column should receive the 
 principal treatment, which consists of adjustment of its various 
 component vertebrae. 
 
 COLD FEET and hands indicate poor circulation in those 
 parts. In some female diseases the coldness of the extremities 
 is very marked, the hands being cold even on warm days. The 
 circulation THROUGH THE PELVIC ORGANS is retarded, affecting 
 the blood supply to and from the lower limbs. The blood is 
 thin and poor in quality; the heart is weakened and unable to 
 force the blood around the circuit and thus overcome the resist- 
 ance offered by the pelvic blood vessels. 
 
 The treatment for such conditions consists in removing ob-
 
 REFLEX DISORDERS. 481 
 
 structions to the venous return, which in the lower limbs, are 
 found in the saphenous opening or at the iliac veins. Correcting 
 partial or complete dislocations of the hip and innominate bones, 
 is often sufficient to overcome this condition in the lower limbs. 
 Treat to increase the amount of pure blood and the rapidity of 
 the blood current, this being accomplished by correcting liver 
 and heart diseases as well as local disturbances of the limbs. 
 
 HYSTERIA is a term used to denote certain nervous mani- 
 festations not due to organic disease. Formerly it was thought 
 to be due to uterine disease, hence its name, but is now regarded 
 as a disorder of the mind, frequently resulting from uterine or 
 ovarian disease. 
 
 It is, in fact, a DISEASE, and should be treated as such. If 
 there is a disturbance of the nervous equilibrium resulting from 
 an imaginary or real disease, it preys on the patient's mind until 
 she gives vent to her feelings. When she does give way to her 
 feelings and loses control of herself we call it hysteria. 
 
 Hysteria is not by any means confined to the female sex, but 
 also affects the male, although less frequently. Some of the worst 
 cases of hysteria I have ever seen, were in the male in which there 
 w T as a supposed impotency. 
 
 HYSTERIA is most commonly found in the UNMARRIED and 
 STERILE; the shock and pain of childbirth tending to prevent its 
 occurrence in multiparae. Incases of malnutrition, general im- 
 pairment of the ovary, or in case there has been a marked 
 laceration causing a loss of nerve force, HYSTERIA is liable to 
 appear, since these conditions render the nervous system un- 
 stable from the loss of nerve force or the lack of formation of 
 same. 
 
 Ovarian irritation is a prolific cause of hysteria. That part 
 of the abdomen over the ovary is especially tender, which is in- 
 
 31
 
 482 DISEASES OF WOMEN. 
 
 dicative of ovarian congestion or inflammation, and in some 
 cases the ovary is prolapsed and congested from frequent sexual 
 excitements. 
 
 Hysteria commonly occurs in people who do not have to 
 work and have time to indulge in morbid fancies. Even a GREAT 
 DEAL OF MUSCULAR WEAKNESS or fatigue is imaginary, not real. 
 To test this let there be a sudden fright and the patient will just 
 .as suddenly forget all about the supposed weakness. 
 
 The sensory disturbances in hysteria are quite well marked. 
 In one spot or region there will be hyperesthesia, in another anes- 
 thesia, the hyperesthetic regions occurring in zones or belts fol- 
 lowing the course of one or more ribs. The patient often com- 
 plains of a certain tender spot which varies from time to time in 
 position, indicating that it is not an organic disturbance. 
 
 Others apparently have a fit or faint. In such cases ex- 
 amine the pulse and note the temperature. If the pulse is reg- 
 ular and strong and the patient does not have an abnormal tem- 
 perature, that is neither too high nor too low, do not be alarmed 
 as death seldom takes place under such conditions. Also ex- 
 amine the PUPILLARY REFLEX. This is done by touching the 
 eyeball with the finger. If it is hysteria, the patient will flinch 
 and suddenly close the eye; if true epilepsy no reflex will be pres- 
 ent, indicating complete unconsciousness. Some complain of 
 an acute pain over and in the ovary. If it is real the patient will 
 not forget about it when you change the subject of conversation 
 to one in which she is interested, as she will if the pain is imagi- 
 nary. 
 
 NUMBNESS, or ANESTHESIA, is sometimes complained of but 
 by severely pinching the parts or touching them with the lighted 
 end of a match the numbness will instantly disappear. If the 
 patient is truly unconscious she will not resist heat; otherwise she
 
 REFLEX DISORDERS. 483 
 
 will, since it is impossibe to so control the muscles that a reflex 
 action will be prevented when intense heat is applied. Of course 
 it would not be policy to resort to such treatment unless the diag- 
 nosis were certain. 
 
 GLOBUS HYSTERICUS, or the sensation of a knot in the throat 
 which interferes with deglutition, is a common symptom. This 
 is due to a contraction of the throat, swallowing of air or an en- 
 largement of the thyroid gland. Clavus hystericus is a symp- 
 tom sometimes found, which is characterized by a sharp, local- 
 ized pain as if one were driving a nail through the skull. 
 
 HYSTERICAL CONTRACTURES and paralyses are found, the 
 patient firmly believing that she can not move a certain joint, 
 and in time the tendons contract producing DEFORMITY of the 
 parts. Hysterical aphonia often occurs during the menstrual 
 period. I remember a patient treated at the A. T. Still Infirmary 
 that had complete aphonia at each menstrual period. After 
 some neck treatment, but especially after she was made VERY 
 ANGRY, the voice returned. In many such cases the nervous 
 system has to be changed, this being best accomplished by means 
 of a shock. 
 
 QUIVERING of the EYELIDS is one of the best symptoms of 
 hysteria. It shows a forced contraction of the muscles, which 
 finally tire and quiver. In some there is a hysterical COUGH 
 OR CRY, the patient being completely overcome by emotion. Gas 
 is usually found in the stomach and intestines, producing tym- 
 panites, borborygmus and eructations. HYSTERICAL FEVERS 
 or TEMPERATURES have been recorded, in which the thermometer 
 registered as high as 115 degrees Fahrenheit. The HYSTERICAL 
 CRY or groan is sometimes found. CATALEPTIC OR TRANCE-LIKE 
 conditions or spasms with opisthotonous are common in advanced 
 cases of hysteria. The patient tears the bedclothes, RETRACTS 
 the head and cannot be kept in any one position.
 
 484 DISEASES OF WOMEN. 
 
 The diagnosis of this condition is sometimes very difficult 
 as well as important. A sad mistake would be made if a real 
 disease were treated as a hysterical one. If a localized lesion is 
 found, it matters not whether there is a hysterical condition or 
 not, if the lesion is corrected. If the supposed lesion or tender 
 spot varies from place to place it is hysterical. If the tempera- 
 ture and pulse are normal, and there is a knot or swelling in the 
 throat, quivering of the eyelids, pupillary reflex, it occurring at or 
 near the periods, ovarian hyperesthesia and pain, and tender 
 points in the back, changing from time to time to different loca- 
 tions, it is safe to pronounce the case a hysterical one. 
 
 The treatment is one directed to change the mind into differ- 
 ent channels. Pressure over the transverse process of the atlas 
 is a good treatment to bring the patient out of one of the spasms. 
 Pain produced in any part of the body is often sufficient to change 
 the thoughts and bring the patient to her senses. 
 
 The patient should be instructed to make an attempt at 
 SELF-CONTROL, not permitting herself to give way to her feelings. 
 Imaginary operations or suggestive treatments are quite success- 
 ful, if the patient gets the idea that the trouble has been removed. 
 In such cases the various "healers" are successful since there is no 
 organic trouble. Dr. C. E. Still had a patient who believed that 
 all his joints were dislocated and nothing could dislodge that idea 
 until each joint was carefully and separately treated and he told 
 it had been replaced. The patient immediately recovered, since 
 it was only an imaginary disease. 
 
 Lesions along the spine and lower ribs are to blame for some 
 hysterical cases, by producing ovarian or uterine disease with 
 the accompanying disturbances. The second lumbar is the most 
 important point, and in the majority of cases, a lesion will be 
 found at that point. Uterine displacement should be corrected.
 
 REFLEX DISORDERS. 485 
 
 and you will find most of them have, to hear them tell it, all the 
 diseases peculiar to the female sex, in fact, they frequently have 
 "UTERUS ON THE BRAIN." 
 
 HYSTERO-EPILEPSY is a form of epilepsy due to disease 
 of the generative organs, USUALLY the OVARY. It is character- 
 ized by an attack very similar to epilepsy, there being a PRO- 
 DROMAL STAGE hi which there are the aura, the stage of CLONIC 
 contraction and the stage of TONIC contraction, followed by the 
 stage of relaxation. During these different stages the patient 
 is in most cases unconscious and sometimes froths at the mouth. 
 
 If a chronic case, the patient has that dull, stupid expression 
 characteristic of epilepsy, which is indicative of impairment of 
 the mind. The attacks are most frequent and hardest near the 
 menstrual period and especially just following the cessation of 
 the flow. About the first thing noticed, is a contraction or, as 
 they express it, a ball, lump or knot, that begins to form in the 
 side just above the ovary, the left being more frequently affected. 
 This contraction gradually ascends through the esophagus to 
 the throat and when it reaches that point the patient has a chok- 
 ing sensation and becomes unconscious. This is the DIAGNOSTIC 
 POINT between hystero-epilepsy and true epilepsy. Whenever 
 the aura begin in the ovary and ascend, and if there is chronic 
 uterine or ovarian disease, and the attack is associated with the 
 menstrual period, it is in most cases hystero-epilepsy. 
 
 The attacks vary in number from one to a dozen per day, 
 being followed by a quiescent period of several days. 
 
 The lesions in such cases are in the cervical and lumbar re- 
 gions. The lesions affecting the uterus and ovaries are the pre- 
 disposing causes; the cervical lesions the exciting causes, which 
 weaken the cerebral circulation. Displacement of the lower 
 ribs may excite ovarian disease and in this way produce epilepsy.
 
 486 DISEASES OF WOMEN. 
 
 A displaced uterus will displace the ovaries, thereby setting up a 
 disease in them. If this ere the only cause every displace- 
 ment would produce epilepsy; but there must be another cause 
 acting in conjunction with the above mentioned ones and this 
 is found to be a LESION IN THE NECK, which weakens the blood 
 supply to the higher centers. 
 
 The attacks usually occur at night. There is hallucination, 
 spasms and a quiescent stage, during which the patient has la- 
 bored respiration and anesthesia. The recovery is gradual and 
 the patient does not remember what has occurred. The urine 
 is limpid and increased in amount, and sometimes involuntarily 
 voided during an attack. In rare cases the tongue is bitten. 
 The muscles are sore and the eyes red after an attack. 
 
 The treatment consists of correction of the ovarian and 
 uterine disease, and the bony lesions usually found in the lumbar, 
 sacral and cervical regions. A displaced uterus or ovary is usually 
 found, upon the replacement of which the symptoms frequently 
 are relieved. After the attack is well under way it cannot be 
 stopped, but if only in the beginning, strong inhibition in the 
 suboccipital region and local treatment by which the uterus is 
 lifted up will often ward it off. 
 
 CATALEPSY is occasionally found accompanying female 
 diseases. The patient becomes perfectly rigid, unconscious and 
 remains that way for some time. A sudden uterine displace- 
 ment will produce this condition. Dr. C. E. Still reports a case 
 in which a woman was walking along the street and, slipping on 
 the walk, fell and suddenly became unconscious and rigid. The 
 usual restoratives were applied but to no avail. He was then 
 called and by REPLACING THE UTERUS, INSTANTLY relieved the 
 condition. I have had similar cases which were relieved by re- 
 placing a displaced uterus or simply changing its position. If the
 
 REFLEX DISORDERS. 487" 
 
 condition comes on suddenly as the result of a lift or fall the 
 
 UTERUS IS TO BLAME IN NEARLY EVERY CASE. After the USUal 
 
 treatments have failed to relieve, examine the pelvic organs for 
 uterine displacement, since this is the cause in a majority of all 
 diseases in the female, and particularly if a history of a fall or 
 strain from lifting can be obtained.
 
 488 DISEASES OF WOMEN. 
 
 MISCELLANEOUS AFFECTIONS. 
 
 STERILITY is not a disease within itself, but a result of dis- 
 eased or badly developed sexual organs. By sterility is meant 
 
 the LACK OF CAPACITY FOR IMPREGNATION OR CONCEPTION. One 
 
 marriage out of every seven is barren and the per cent, is on the 
 increase. The fault is usually attributed to the female, but the 
 male is very often to blame. 
 
 In order to understand sterility it is first necessary to under- 
 stand the factors that enter into impregnation. 
 
 The cortical portion of the ovary contains Graafian follicles 
 in which are the ova. At the maturity of a follicle it ruptures, 
 throwing out the ovum which is carried by way of the Fallopian 
 tubes to the uterus. If at this time semen is present in which are 
 the active spermatozoa, union takes place, supposedly in the Fallo- 
 pian tubes. If the NIDUS is healthy enough to nourish the now 
 impregnated ovum, it remains firmly attached to the mucous 
 lining. Therefore, in order that impregnation take place there 
 must be a union of the ovum and the spermatozoon and a healthy 
 nidus from which nourishment can be drawn. From this it can 
 be seen that sterility would follow (1) ABSENCE of one or both 
 vital elements; (2) PREVENTION OF UNION of the two vital ele- 
 ments; or (3) DESTRUCTION of the impregnated ovum just after 
 union had taken place. 
 
 ABSENCE of the spermatozoon is the result of disease or 
 weakness of the testes. In gonorrheal subjects, or in those ad- 
 dicted to the practice of masturbation, or excessive venery the 
 semen often lacks the vital element. To test the semen, a 
 microscopic examination should be made whereby the sper-
 
 MISCELLANEOUS AFFECTIONS. 489 
 
 matozoa can be seen if present. They are active and resemble 
 tadpoles in shape. 
 
 Ovarian disease, such as ovaritis, tumors, atrophy or non- 
 development, prevents the maturing of the Graafian follicles 
 and escape of the ova, thus producing sterility. In the obese 
 the ovary is usually inactive, hence the amenorrhea and sterility. 
 
 Lesions affecting the ovarian centers impair the activity of 
 the ovary and cause sterility. This has been proven by cases 
 treated by us. These lesions also interfere with the proper devel- 
 opment of the ovaries and uterus. A poorly or non-developed 
 uterus is very often the cause of sterility. There is usually an 
 anteflexion, the cervix being drawn forward and distorted, and 
 the anterior lip flattened in many cases. AFTER SEVERAL YEARS 
 of MARRIED LIFE the ovaries and uterus sometimes become de- 
 veloped and impregnation takes place. If impregnation does 
 not occur within FOUR OR FIVE years after marriage, the chances 
 are that the CASE is INCURABLE, although the writer has cured 
 cases of many years standing, by correcting spinal and visceral 
 lesions. A small uterus with a conical or flattened cervix and a 
 pin-hole os is almost pathognomonic of sterility. 
 
 The ovum may be PREVENTED FROM REACHING the tubes or 
 uterus by disease of the tubes, such as salpingitis or a closure of 
 the canal. The SPERMATOZOON may be prevented from reaching 
 the tubes by an acute flexion, stenosis, atresia of the vagina or a 
 closure of the uterine end of the tubes. Abnormalities which 
 prevent intercourse in a similar way cause sterility. 
 
 Diseases of the vagina which prevent intercourse, such as 
 vaginismus, vaginitis or an inflammatory condition of the urethra 
 and vulva, also cause sterility. Again, the SPERMATOZOA 
 MAY BE DESTROYED after they have been deposited in the vagina. 
 If the environment is suitable they will live for some time. ACID 
 SECRETIONS destroy them, since they are alkaline.
 
 490 DISEASES OF WOMEN. 
 
 Leucorrheal discharges, by counteracting the spermatozoa, 
 cause sterility. Metritis and endometritis also predispose to 
 sterility. A LACERATED CERVIX causes both metritis and endo- 
 metritis with the attending leucorrheal discharge. Endometri- 
 tis causes sterility, not only by destroying the spermatozoa but 
 by weakening or destroying the nidus which should be ready for 
 the reception of the impregnated ovum. CONSTITUTIONAL dis- 
 eases such as anemia and scrofula, in which the blood is thin, 
 tend to produce sterility. The ovaries are inactive, the Graafian 
 follicles do not develop and rupture, hence the ovum is not ma- 
 tured. 
 
 THE TREATMENT should as in every disease, be applied to 
 the existing cause. Be sure the trouble is not in the husband, 
 for in this age in which gonorrhea and masturbation are so com- 
 mon, the male is very often to blame. If the ovaries are inactive, 
 endeavor to correct the lesions which impair their influence, 
 these being found in the lower dorsal region or in the lower ribs. 
 If there is a flexion or a stenosis of the os uteri, it should be cor- 
 rected; if leucorrhea exists to any great extent it should be re- 
 lieved since the acidity will counteract the alkalinity of the sper- 
 matozoa. Inflammatory conditions must be overcome before 
 the condition can be cured. The best treatment, and the one 
 with which I am most successful, is one applied to the lower dor- 
 sal and upper lumbar regions. Strong stimulation and manip- 
 ulation of the spinal column by which each vertebra is adjusted, 
 FREE THE BLOOD AND NERVE SUPPLY to the pelvic organs, which 
 is necessary to their health. If the general health is impaired 
 it will have to be built up, otherwise impregnation will not take 
 place, or, if it does, abortion is likely to follow. 
 
 LEUCORRHEA is another condition which is a symptom of 
 SOME VASCULAR DISTURBANCE affecting the mucous secreting
 
 MISCELLANEOUS AFFECTIONS. 491 
 
 glands of the vagina and uterus. It is defined as a muco-puru- 
 lent discharge, popularly called the "whites," from the female 
 genital tract. The discharge comes either from the vaginal walls 
 or the uterus, hence the division into vaginal and uterine leucor- 
 rhea. 
 
 Normally there is a secretion from the vagina JUST SUFFI- 
 CIENT TO LUBRICATE THE PARTS. This is a clear, transparent, 
 glairy fluid like the white of an egg. That from the uterus is 
 alkaline; that from the vagina acid. When these secretions are 
 abnormal in quality, or especially in quantity, it is called leucor- 
 rhea. As mentioned before, an increased arterial blood flow to 
 a gland increases its physiolgical secretion, while an increased 
 venous flow produces a pathological secretion. 
 
 CAUSES. The cause of leucorrhea depends upon a venous 
 congestion of the uterus and vaginal walls, usually the result of 
 obstruction or vaso-motor paralysis. The use of WARM WATER 
 DOUCHES is a common cause. Nearly all women use them and 
 about ninety per cent, have leucorrhea. They are especially 
 important as causes, if used daily. Warm water DILATES the 
 blood vessels, producing a slowing of the blood current. From 
 this will result a lowering of the vitality of the blood with its 
 increased amount of poisonous materials, which go to make up 
 the venous condition. This affects the activity of the glands 
 and produces a weakness in the uterus and supports, following 
 which DISPLACEMENTS and MENSTRUAL DISORDERS are found. 
 In the parous woman examine for a lacerated cervix. If the in- 
 jury is very long in healing, the parts become congested and fol- 
 lowing this is usually an abnormal secretion. 
 
 Sometimes an EROSION or ULCERATION is present. In such 
 cases there is a constant irritation, ache, and discharge of a muco- 
 purulent nature.
 
 492 DISEASES OF WOMEN. 
 
 A displaced uterus causes a congestion of the different glands, 
 hence is a common cause of leucorrhea. The discharge is worse 
 during the menstrual period, since the parts are more congested 
 at that time. 
 
 VAGINITIS, either simple or specific, is a cause of the va- 
 ginal form. Gonorrheal vaginitis, especially in the latent or 
 chronic form, is quite a prominent cause. 
 
 Bony lesions which interfere with the vaso-motor supply, 
 are the most important causes as viewed from the osteopathic 
 standpoint. These lesions are found in the lower part of the 
 spine in the form of a subluxated vertebra or a curvature, and in 
 the pelvic region in the form of a displaced innominate, sacrum 
 or coccyx. Case after case can be cited in which cures were 
 effected by simply correcting the bony lesions. 
 
 In some cases leucorrhea is due to GENERAL DEBILITY the 
 result of stomach affections or constitutional diseases. I have 
 seen cases follow attacks of typhoid fever. In such cases a le- 
 sion is found in the middle or lower dorsal region affecting the 
 nutrition, AND FROM POOR NUTRITION RESULTS DISTURBED SE- 
 CRETIONS. The uterus and vagina share in the general weak- 
 ness and leucorrhea is the consequence. Remember that a 
 venous congestion is a condition ALWAYS FOUND IN LEUCORRHEA, 
 whether due to inhibition of the vaso-motor nerves or a mechan- 
 ical obstruction preventing free return of the blood to the heart. 
 
 SYMPTOMS. The principal symptoms of leucorrhea, besides 
 the discharge, are BACKACHE, general weakness and menstrual 
 disorders, especially too long and profuse menstruation. The 
 discharge has in most cases a very disagreeable odor on account 
 of the decomposition which has taken place. If chronic, it des- 
 iccates and forms into lumps, while in the early stages it is of a 
 slimy, glairy nature. This discharge, from the color and its ef-
 
 MISCELLANEOUS AFFECTIONS. 493 
 
 feet on the nervous system, has given rise to the belief among the 
 laity that the white stuff is the spinal marrow which melts and 
 escapes through the genital tract. 
 
 During an attack of epilepsy this discharge is markedly in- 
 creased. Uterine displacements, standing on the feet, and vari- 
 ous diseases increase the amount of the discharge. All abnormal 
 discharges, whether the color is white or tinged with blood, are 
 classified under the head of leucorrhea. 
 
 PROGNOSIS. The prognosis is very uncertain. Some cases 
 yield very readily to treatment, while others are slow. If the 
 cause is readily found and can be easily corrected it is favorable, 
 but if it occurs in an anemic, weak person in whom the blood is 
 thin, the progosis is unfavorable for a rapid cure. 
 
 TREATMENT. The treatment consists in relieving the con- 
 gestion of the uterus, which is accomplished by locating the 
 cause and correcting it in each individual case. It is one of the 
 most common disorders, and one which is due to MANY CAUSES, 
 hence the treatment must be given according to the causes in 
 the individual case. 
 
 In the first place, CORRECT THE BONY LESIONS, whether in 
 the dorsal, lumbar or sacral region ; also uterine displacements, 
 since they cause venous stasis. Treat over the veins leading 
 from the uterus, in this way relieving the stagnated condition in 
 the uterus. Strong stimulation of the nerves in the lower lum- 
 bar and sacral regions is very good and tends to restore tonicity 
 to the vessel walls. By correcting the anatomical derangements, 
 assimilation is improved, glandular action regulated and secre- 
 tions made normal. If the leucorrhea is due to a general or 
 constitutional disease, the general health must be improved be- 
 fore a cure is effected. Douches are sometimes necessary for 
 the sake of cleanliness and should be used occasionallv if the odor
 
 494 
 
 DISEASES OF WOMEN. 
 
 becomes too offensive. Salt added to the water is of value in 
 cleansing the parts. Some claim that leucorrhea can be cured 
 by the repeated use of saline injections. Perhaps the secretion 
 can be lessened in amount, or even temporarily checked, but the 
 cause remains and the effect will return. 
 
 I once heard the "Old Doctor" say that the exudate thrown 
 out in tonsillitis or in any so re, that is the scab, is FOR THE PURPOSE 
 
 Fat. 
 Lobule unravelled. 
 
 Lobule. 
 
 Lactiferous duct, 
 
 * 
 Ampulla. 
 
 >* 
 
 Loculi in connective tissue. 
 
 Fig. 108. Dissection of the lower half of the female breast during the 
 period of lactation. (Luscka.) 
 
 OF PROTECTING THE INFLAMED Or DISEASED SURFACE which it 
 
 covers. Perhaps leucorrhea acts in a similar way; that is, the 
 uterus and vagina throw out a secretion which coats the inflam- 
 ed mucous membrane, thus protecting it. If this is true, it sug- 
 gests that primarily, leucorrhea is due to an inflamed surface
 
 MISCELLANEOUS AFFECTIONS. 495 
 
 which nature is trying to protect and that astringents used to 
 destroy or remove this secretion are injurious rather than help- 
 ful. We know this is true of the various throat washes or 
 gargles, such being harmful in tonsillitis and pharyngitis. In 
 the very chronic cases in which the secretions have been de- 
 posited in quantities in the fornices, they should be removed. 
 This can be done with dressing forceps and absorbent cotton. 
 
 MASTURBATION is a vice which has become very prevalent. 
 Although not practiced so extensively by the female as by the 
 male, its effects can be seen depicted on the faces of many. In 
 some it is the result of disease; in others it has been brought on 
 by obscene literature or bad associations. A lesion which stim- 
 ulates the PUDIC nerve will often lead to masturbation. This 
 lesion is usually found in the lower dorsal region. An adhered 
 clitoris, uncleanliness or pruritus vulvae are common causes. It 
 is most commonly found in the young, but occasionally in the 
 adult. 
 
 "A very serious mistake in general is made as to the loca- 
 tion of the parts which play the chief part in the orgasm. The 
 clitoris in the female is usually put down as the part chiefly in- 
 volved. Whether in the male or the female, the urethra is the 
 part in which the orgasm occurs. In the male it is caused by the 
 passing of jets of semen over the mucous membrane of the urethral 
 canal. In the female, by jets of mucus from the neck of the 
 bladder through the urethra. After an orgasm in the female, 
 "however produced, the labia and vestibule are flooded with mu- 
 cus, which escapes not from the vagina altogether, but largely 
 from the urethra. The reason why males who have suffered 
 amputation of the glans, and women who have been deprived of 
 the glans of the clitoris can still accomplish the sexual act with 
 orgasm, is because the urethra is the seat of the peculiar nerve
 
 496 DISEASES OF WOMEN. 
 
 distribution necessary for its production. This explains the 
 habit of some individuals of passing all manner of objects into 
 the urethra, and even masturbating that way." 
 
 SYMPTOMS. Masturbation, at first, if not excessive, pres- 
 sents no special symptoms. If excessive, it first shows itself in 
 the form of nervousness. The complexion is pale, sallow, and 
 the eyes sunken and surrounded by dark rings; the patient is 
 bashful and has a secretive, downcast expression; the hands and 
 feet are cold, the skin clammy, circulation poor, there being a 
 small, rapid, weak pulse and shortness of breath. The general 
 health becomes deteriorated and the patient non-energetic. The 
 step is not elastic and the victim is given to MORBID FANCIES. 
 IN CHILRDEN convulsions or SPASMS MAY DEVELOP, which are 
 very hard to understand. I have seen cases of spasms which 
 would occur only at night, cured by correcting a diseased clitoris 
 which had brought on masturbation. In describing the signs 
 Dickinson, in American Gynecology, says: "The type of full 
 development of the deformity consists in a finely wrinkled and 
 deeply pigmented enlargement of the labia majora and hyper- 
 trophy of some adjacent structures. Thickened, enlongated, 
 curled on themselves, thrown into tiny, close-set, irregular folds 
 that cross at all angles, as in a cock's comb, the lesser labia pro- 
 trude in all positions through the larger labia. The pigment 
 deposit varies with the general type of coloring. One labium is 
 sometimes greater than its fellow. The follicles are often con- 
 spicuous as whitish spots, the prepuce commonly, and the 
 fourchette occasionally, participate in the corrugation and dusk- 
 iness, or one of these may alone be affected. At times a wrinkled 
 band runs off to the labium majus. Certain veins near the clit- 
 oris stand out. At the mouths of each urethral gland a flap-like 
 protrusion may be seen. Greater size and power of the pelvic
 
 MISCELLANEOUS AFFECTIONS. 497 
 
 floor accompany the other hypertrophies. Distinctive increase 
 in the size of the clitoris may be present, but contrary to the gen- 
 eral belief, it is infrequent. There may be enlargement and 
 changes in the areolae or in the breasts, resembling those of preg- 
 nancy. At a later stage flabbiness of the labia majora, or pig- 
 ment spots denote atrophy of the structures once enlarged, but 
 the small marks never disappear. Some part or the whole of 
 these alterations occur in about one third of those women who 
 suffer from pelvic disorders. One fourth of the patients present- 
 ing hypertrophies belong to the neurotic class. These altera- 
 tion are due to oft- repeated, prolonged sexual excitation, irre- 
 spective of coitus or gestation. Pressure or friction causes them. 
 Pregnancy produces increase of size and some surface irregu- 
 larity, but never the fully developed changes here specified." 
 
 The most important effect of masturbation is on the NERV- 
 OUS system. Nervousness, morbid fears and fancies, melan- 
 cholia, solitude and loss of memory are common. In nearly all 
 cases there is ovarian pain, the result of repeated congestion of 
 the ovary. Another effect is that of bowel disease. One writer 
 says: "Next in importance is the disturbance of the intestinal 
 functions. Intestinal indigestion, distention with gas; wake- 
 fulness, as a consequence, is common in these patients. A pe- 
 culiarly obstinate constipation is a most common accompaniment. 
 During the manipulation of the genitals, the sphincter and leva- 
 tor ani muscles are CONTRACTED TO THE UTMOST. It is a part of 
 the process whereby an orgasm is produced. The result is a 
 
 TONIC CONTRACTION OF THE SPHINCTER ANI MUSCLE. Constant 
 
 taking of laxatives or cathartics adds to the trouble by destroy- 
 ing the muscular tone of the rectum and colon. An examina- 
 tion of the rectum in these cases shows the mucous membrane 
 relaxed and frequently in deep and multitudinous folds, filled 
 
 32
 
 498 DISEASES OF WOMEN. 
 
 with glairy mucus; the sphincter will scarcely admit the well- 
 oiled finger." 
 
 TREATMENT. The treatment consists of two things; first, 
 bringing to bear a moral suasion if the patient is accountable; 
 second, removing the source of irritation which provokes the 
 practice. In those who are naturally passionate a VEGETABLE 
 diet, as well as morality, should be enforced. 
 
 Work, either physical or mental, by which the mind is busied, 
 is one of the best remedies- If the patient is idle, with nothing 
 to occupy the mind, masturbation is very apt to be contracted; 
 but if the mind is busy there is no room for evil thoughts. THE 
 
 BLOOD IS DISTRIBUTED TO EVERY ORGAN ACCORDING TO THE ACTIV- 
 ITY OF THAT ORGAN. If the patient constantly has sexual irri- 
 tation from the influence of the higher centers, the organs become 
 congested and secretions increased. Cold baths are beneficial 
 in that they stimulate the circulation and cause equal distribu- 
 tion of the blood. Again, if there are lesions they should be re- 
 moved. I have seen cases of NYMPHOMANIA cured by correcting 
 a lesion at the TENTH DORSAL VERTEBRA, which in some way 
 caused a stimulation of the pudie nerve. 
 
 The removal of smegma or local accumulations of filth about 
 the clitoris is necessary, since any local irritation has a tendency 
 to lead to the condition. SLEEPING ON THE BACK is contra-in- 
 dicated, since the centers in the cord controlling the sexual organs 
 become congested and deranged by the settling of blood, that is, 
 the hypostatic congestion while in that position. 
 
 ABORTION is technically defined as the expulsion of the pro- 
 ducts of conception at, or before, the third month, but ordinarily 
 it is understood to be the TERMINATION OF PREGNANCY before the 
 seventh month or viability. Abortion occurs quite often; at 
 least twenty-five per cent, of all cases of pregnancy abort, and
 
 MISCELLANEOUS AFFECTIONS. 499 
 
 the practitioner will be called upon to treat such cases, or at least 
 to diagnose them. In some, abortion becomes habitual. The 
 WRECK of many a WOMAN'S CONSTITUTION can be traced to one 
 or repeated abortions. It may occur at the first month, the pa- 
 tient thinking it a case of membranous dysmenorrhea accompanied 
 by flooding, or it may occur at the third month, at which time it 
 is most common, probably on account of the formation of the 
 placenta at this time. 
 
 CAUSES. Abortion depends especially upon one thing, 
 viz: STRONG UTERINE CONTRACTION; consequently, anything 
 that will bring on marked uterine contractions will bring on 
 abortion. A weakened attachment of the embryo is a predis- 
 posing cause. It may be caused by disease of the fetal append- 
 ages, malposition of the placenta and abnormalities of the cord. 
 PATERNAL causes are sometimes found, such as syphilis, or where 
 the spermatozoa are weakened from constitutional diseases, ven- 
 ereal diseases, excesses, masturbation or extreme old age. MA- 
 TERNAL causes are common, such as the exanthemata or other 
 diseases, systemic poisons, or lesions along the lower part of 
 the spine. These lesions weaken the uterus, hence the attach- 
 ment of the ovum is insecure. ALL FORMS OF TRAUAIATISM, such 
 as blows, strains or the lifting of heavy weights, produce abortion 
 if there are any predisposing causes. The INTRODUCTION OF IN- 
 STRUMENTS INTO THE UTERINE CAVITY, s.uch as a sound or cathe- 
 ter, persistent vomiting, hiccoughing or sneezing may produce 
 it. It may be brought on by various reflex causes, such as vio- 
 lent emotion or sudden excitement, if severe enough, or if there 
 is a marked predisposition. 
 
 Produced abortion is the result of the introduction of instru- 
 ments into the uterus or by the ingestion of certain drugs, such 
 as tansy, ergot or pennyroyal.
 
 500 DISEASES OF WOMEN. 
 
 To the osteopath the LESIONS ARE THE MOST IMPORTANT, 
 and if such exist in a pregnant woman, be very careful NOT TO 
 PRODUCE PAIN while treating the patient, since abortion may 
 occur. Again, by PROPERLY TREATING SUCH LESIONS, ABORTION 
 
 MAY BE PREVENTED. 
 
 SYMPTOMS. The symptoms vary with the stage to which 
 gestation has advanced. The prodromal symptoms are: sense 
 of discomfort in the pelvis, pain in the lumbar and sacral regions 
 and a general uneasy feeling. These symptoms are followed by 
 hemorrhage, uterine contractions or labor pains and finally by 
 the expulsion of the embryo or a part of the products of concep- 
 tion. 
 
 The cervix, on local examination, will be found soft and 
 the os patulous, if it is a case of INEVITABLE abortion or if it 
 has already taken place. The mammary glands will be found 
 enlarged and the milk secretion will usually occur at the third 
 day after abortion. 
 
 The diagnosis is made by finding the embryo or its mem- 
 branes. Often these are lost, the mother not thinking of their 
 diagnostic value, thus making it hard to diagnose. If there is 
 retention of the membranes it may give rise to puerperal fever, 
 or if chronic, the symptoms may be similar to those of a dead 
 fetus, cancer or sloughing polypus. 
 
 The AFTER EFFECTS or sequelae are of most interest to the 
 gynecologist. The local after effects are those resulting from 
 subin volution. The uterus remains large, soft and vascular for 
 several months ; a relaxation of the uterine supports permits dis- 
 placements to occur from any exciting cause; the vaginal walls are 
 smooth, that is the rugae are absent, but folds of mucous mem- 
 brane are present in their stead; the os is patulous, the cervix 
 short and thick. LEUCORRHEA in a verv bad form usuallv com-
 
 MISCELLANEOUS AFFECTIONS. 501 
 
 plicates. The nervous symptoms are the most important, tha 
 patient sometimes becoming a nervous wreck. Neurasthenia, 
 nervous prostration and general malnutrition are common se- 
 quelae. 
 
 TREATMENT. The prophylactic treatment consists in cor- 
 recting lesions which weaken the uterus, and PREVENTING any 
 EXCITING cause which would bring on uterine contractions. 
 Avoid strains, traumatism and emotional excitements, since 
 they produce abortion if any predispositon exists. 
 
 The TREATMENT of threatened abortion consists in putting 
 the patient to bed and keeping her perfectly quiet with the hips 
 elevated. Stimulation of the clitoris causes contraction of the 
 cervix; this is accomplished by pressing on the clitoris with the 
 thumb and then letting it suddenly slip off. This is productive 
 of pain which causes retraction of the uterus. If the cervix is 
 not obliterated and os has not dilated to any degree, the abortion 
 can be stopped in this way. 
 
 Inevitable abortion follows dilatation of the os uteri. In. 
 such cases the treatment is almost identical with that given in 
 normal labor, that is, inhibition of the clitoris to relax the cervi- 
 cal muscle fibers, and stimulation of lumbar region to bring on 
 contraction of the fundus or labor pains. If the membranes are 
 not expelled on account of non-loosening of the placenta and 
 NO HEMORRHAGE is PRESENT, wait awhile for the uterine contrac- 
 tions to loosen it. After the placenta has been separated from 
 the uterus, remove by means of a pair of abortion forceps. Pro- 
 duce contraction of the uterus to prevent hemorrhage, keep the 
 patient quiet until involution is well under way, and the re- 
 covery is, as a rule, rapid. 
 
 The diagnosis is the principal point of interest to the gyne- 
 cologist, and to be sure of this, consider the early signs of preg-
 
 502 DISEASES OF WOMEN. 
 
 nancy, hemorrhage, size of os, onset, reflex disturbances and 
 history of case. All HEMORRHAGES IN MARRIED WOMEN are to 
 be regarded with suspicion. 
 
 The IMMEDIATE DANGERS are hemorrhage, laceration and 
 puerperal fever from retention of a part of the fetal membranes. 
 The SECONDARY DANGERS are habitual abortion, uterine displace- 
 ments and subinvolution, which cause chronic backache, head- 
 ache, menstrual disorders, inflammation of the uterus, and a 
 general sense of weakness or fatigue. 
 
 ECTOPIC GESTATION and extra-uterine pregnancy are 
 terms used to denote that gestation has occurred outside of the 
 uterine cavity. It is a rare condition, but is occasionally found. 
 It may take place in the TUBES, PERITONEAL cavity or the OVARIES. 
 It is supposed to be due to retention of the ovum in those places 
 from some interference with its transmission to the uterus, and 
 the union with the spermatozoon therefore taking place at that 
 point. Chronic salpingitis, displacements of the ovary or chron- 
 ic peritonitis tend to destroy the ciliated epithelium, therefore 
 preventing the transportation of the ovum to the uterus. Since 
 the ovum is not self-mobile and depends upon the external in- 
 fluences for its movements, and the spermatozoon has the power 
 of locomotion, therefore if the ciliated epithelium were destroyed 
 the ovum would be retained in the peritoneal cavity while the 
 spermatozoon would travel upward through the tube unless the 
 lumen were completely occluded. 
 
 The symptoms of extra-uterine pregnancy are very similar 
 to those of normal gestation. The reflex symptoms are the 
 same; the gastric disturbances are even more marked. Menstrua- 
 tion usually ceases, but in some cases it is not disturbed; mothers 
 it is irregular. There is a discharge of blood mingled with SHREDS 
 OF BROKEN DOWN DECiDUAE. This symptom indicating the for-
 
 MISCELLANEOUS AFFECTIONS. 503 
 
 mation of the decidua vera is one of the most important. The 
 uterus is somewhat enlarged but not so much as in normal 
 pregnancy. The tumor is found at the side of the median line. 
 It is PAINFUL and GROWS rapidly, and on bimanual examination 
 is found to be fluctuating, soft and very sensitive. Pelvic pains 
 are usually very sharp and tearing in character. 
 
 A positive diagnosis is impossible before rupture of the sac, 
 which occurs at about the fourth month. However, if the EARLY 
 SIGNS OF PREGNANCY ARE PRESENT, early appearance of sharp, 
 cramping, pelvic pains, irregular hemorrhages, the uterus not 
 very much enlarged, os dilated and cervix soft, and shreds of 
 deciduae discharged, it is probably a case of extra-uterine preg- 
 nancy. If, in addition, a sensitive, soft, rapid-growing tumor is 
 located in the region of one of the Fallopian tubes, it indicates 
 ectopic gestation. The treatment, which is surgical, consists of the 
 removal of the mass by abdominal section. If rupture of the sac 
 does not occur, as it usually does at the fourth month, it may 
 be retained for years, being partly absorbed and mummified. 
 
 At term the mother has what is called SPURIOUS labor, since 
 she has all the symptoms of labor without expulsion of the fetus. 
 If rupture takes place death usually follows, unless prevented by 
 surgical intervention. 
 
 THE MAMMARY GLANDS are the seat of a great many dis- 
 orders, many of which are reflex from the pelvic organs. Since 
 they are a part of the sexual system, the gynecologist will be call- 
 ed upon to treat disorders occurring in them. 
 
 They are two glands which extend from the third to the 
 seventh rib, from the sternal border to the mid-axillary line. 
 Their size and prominence depend upon a great many things, but 
 principally upon SEXUAL ACTIVITY and whether the patient is a 
 nullipara or multipara. The nipple is located on a level with the
 
 504 DISEASES OF WOMEN. 
 
 fourth rib and is directed outward and upward. The integument 
 covering the nipple is pigmented, the amount varying with the 
 complexion of the patient and whether pregnancy has existed. 
 The gland proper is composed of separate glands, about twenty 
 in number, which open by half as many ducts at the nipple. The 
 nipple has unstriped muscle fibers, on account of which erection 
 may take place. 
 
 The BLOOD VESSELS come principally from the mammary 
 artery byway of its perforating branches through the second, third 
 and fourth intercostal spaces. Some branches from the axillary 
 artery also supply the gland. The veins accompany the arteries. 
 The LYMPHATICS are very numerous and communicate with the 
 axillary lymphatic glands. The NERVES come from the cervical 
 plexus and the fourth, fifth and sixth intercostal nerves, which 
 are accompanied by sympathetic filaments. 
 
 THE FUNCTION of the mammae is to secrete milk for the 
 nourishment of the child for the first twelve months' They have 
 a very close connection with the pelvic organs so that disease of 
 one affects the other. Stimulation of the nipples produces a con- 
 traction of the uterus and excites sexual desire. Immediately 
 following labor the nursing of the child causes an increase of the 
 lochia, since uterine contraction follows the stimulation caused 
 by nursing; and on this account the child should be placed to 
 the breast as soon as possible after labor. 
 
 The size of the gland depends, in most cases, upon the amount 
 of sexual irritation and the age at which puberty appeared. IN 
 
 THE YOUNG, V6FV LARGE MAMMAE denote PRECOCIOUS SEXUAL 
 
 DEVELOPMENT. This development or early puberty follows mas- 
 turbation or sexual excitement from other causes. In others 
 the glands are naturally large. If there is atrophy or non-devel- 
 opment, it indicates that the ovaries are not very active and that
 
 MISCELLANEOUS AFFECTIONS. 505 
 
 the sexual sense is not very well developed. In treating such 
 cases attention should be given the PELVIC ORGANS as well as the 
 RIBS upon which the glands lie. 
 
 DISEASES. The most common disease found is some en- 
 largement or tumor. These enlargements are usually in the 
 lymphatic glands, but are occasionally located in the lactiferous 
 glands. 
 
 The lymphatic enlargements occur at the base. At first it is 
 a kernel about the size of the end of the little finger. It is freely 
 movable and slightly tender on pressure; enlarges very slowly, if 
 at all, and if it is very hard runs a chronic course. It gives rise 
 to no physical inconvenience, but to a great deal of mental anxiety. 
 It is innocent in character unless worked with too much or 
 bruised by manipulation or operations. 
 
 A rather curious thing is noted in many cases of POST-PARTUM 
 MASTITIS. If the lochia is abnormal in any way, the breasts are 
 IMMEDIATELY AFFECTED; and I belie ve that in ninety per cent, of 
 all cases of mastitis, the TROUBLE is, to a great extent, ix THE 
 UTERUS, such as retention of a part of the placenta or lochial dis- 
 charge. In some there is a PARTIAL INVERSION which keeps up 
 an irritation, resulting in subin volution with hemorrhage. In 
 one case of mastitis in which an abscess formed in the breast, 
 there was a discharge from the uterus. It was of a greenish 
 color, and when it was lessened the discharge from the breast in- 
 creased and seemed to be identical in composition with that from 
 the uterus. 
 
 The treatment for mammary diseases in general, consists of 
 correcting the second, third and fourth ribs so as to permit of a 
 free lymphatic circulation, as well as that of the blood. Treat- 
 ments given directly to the enlargement should be very light and 
 I doubt if they are ever indicated. Massage of an inflamed breast
 
 506 DISEASES OF WOMEN. 
 
 for the purpose of emptying it of retained milk is helpful, if proper- 
 ly performed. 
 
 Sometimes FIBROID TUMORS are found in the gland. They 
 are very similar to an enlarged lymphatic gland but are harder, 
 not so tender, and their growth less rapid. They most commonly 
 follow injuries of the ribs, strains of the muscles, traumatism or 
 direct injuries to the glands or muscles in that region. Their 
 course is chronic, growth very slow, and need cause little alarm 
 unless bruised, when they may develop into malignant tumors 
 such as a sarcoma or a malignant adenoma. The treatment con- 
 sists in freeing the circulation to the gland and of gentle manipu- 
 lation to the tumor itself. Operations should be avoided if possi- 
 ble, since they often excite malignancy on account of the injury 
 to the tissues. 
 
 CAXCER of the breast is usually of the scirrhous variety. 
 It is found in the glandular substance proper, and is in most in- 
 stances, the result of bruising of the gland. This bruising may be 
 from accident, too hard a treatment, prolonged nursing or an 
 operation whereby the gland is laid open. It generally begins 
 in SMALL HARD LUMPS in the substance of the breast. Its growth 
 is at first slow, but afterwards rapid. It is located very close 
 to the nipple, and on this account the nipple becomes FIXED and 
 RETRACTED. The skin finally gives way as the swelling increases 
 and a foul ulcer is formed. The lymphatic glands become in- 
 volved and are swollen and tender. The movements of the 
 shoulder and arm are hindered since the pectoral muscles are 
 affected. Soon in a bad case, the constitutional symptoms of 
 cancer appear, followed by death. 
 
 The diagnosis is based upon the retraction of the nipple, indu- 
 ration, rapid progress of the disease, tenderness, ulceration and 
 the constitutional symptoms. A great many cases of SIMPLE
 
 MISCELLANEOUS AFFECTIONS. 507 
 
 TUMORS are MISTAKEN FOR MALIGNANT or made malignant by op- 
 eration. If a lump is found in the breast and it becomes tender, 
 an operation is at once advised. In our practice we have cured a 
 majority of cases of supposed cancer by correcting a displaced rib 
 or ribs. The third or fourth rib is usually found twisted, pro- 
 ducing tenderness at the junction of the ribs with the costal car- 
 tilages, stagnation of the lymphatic and venous circulation with 
 engorgement of the lymphatic glands both in the mammae and 
 axilla. A retracted nipple may result from ovarian disease or 
 non-development but coupled with other cancerous indications, 
 aids in making up the diagnosis. 
 
 TREATMENT. The surgical treatment is extirpation of the 
 gland as soon as possible. The osteopath advises removal, if 
 the disease does not yield to treatment after a sufficient trial 
 has been given. This treatment consists in correcting displaced 
 ribs, the most common being the second, third or fourth, and in 
 correcting lesions of the corresponding vertebrae. 
 
 The symptoms of the rib displacements are, tenderness at 
 the articulations or along the course of the rib, and irregularities 
 of the ribs such as undue prominence of one of the edges or ends. 
 
 TREATMENT OVER the tumor is rarely given if tenderness is 
 present, since it increases the irritation and inflammation. The 
 PAIN in the breast is most commonly in an intercostal nerve and 
 by raising the ribs and using inhibition at the vertebral end, it 
 can be relieved. Remember in mammary affections that the en- 
 largement is due in most cases to swelling of the lymphatic glands 
 or a subluxated rib; that the pain is intercostal and due to a dis- 
 turbance of the intercostal nerve; that operations can be avoided, 
 hence the prevention of malignancy in a great many cases; and 
 that the prognosis is good in most mammary affections. If the 
 case is one of true carcinoma relief can be given but a cure is not 
 probable.
 
 508 DISEASES OF WOMEN. 
 
 CHLOROSIS is a term applied to an anemic condition in 
 young girls at or just after puberty, which is the result of impov- 
 erished blood. The common name is "green sickness/' so 
 named from the yellowish green color of the complexion. 
 
 The causes are HYGIENIC, DIETETIC and LESIONS. Girls who 
 are closely confined to a STUFFY ROOM, ILL-FED, OVER-WORKED . 
 and who take little or no exercise in the open air, are the ones 
 most likely to be attacked. If the patient is approaching, or has 
 just passed puberty, the greater the likelihood of the disease devel- 
 oping. Although such environment and poor food tend to bring 
 on the disease, back of it all are LESIONS affecting the nutrition 
 of the body. These LESIONS are most frequently found in the 
 third, fourth and fifth thoracic vertebrae. The spine is flattened 
 at these points, affecting the LUNGS AND HEART, the two impor- 
 tant organs which have to do with the quality of the blood and 
 its circulation. The heart is affected in these cases, being weak 
 and irritable. The quality of the blood is impaired, there being 
 an anemic state, the red corpuscles being lessened in number and 
 deficient in hemoglobin, hence nutrition suffers. On account of 
 the blood changes the complexion is peculiar, in that it has a 
 yellowish green tinge. The patient tires easily on exertion, 
 there being shortness of breath and palpitation of the heart. The 
 PULSE is accelerated and easily compressed. DIGESTION is im- 
 paired and the patient often has a depraved appetite, such as a 
 desire for crayon, slate pencils, etc. The bowels are sluggish; 
 in fact, the entire gastro-intestinal tract is impaired, this being 
 one of the complications of poor nutrition and assimilation. 
 
 Menstrual disturbances are common, amenorrhea being the 
 usual form. In a small per cent, of cases menorrhagia is present. 
 It seems that the blood loses its power to coagulate, hence when 
 the flow once starts, it continues longer than the normal, since
 
 MISCELLANEOUS AFFECTIONS. 509 
 
 an internal clot forms with difficulty, the formation of such a 
 clot being nature's method of checking any hemorrhage. The 
 EYEBALLS usually have a PEARLY or BLUISH TINT sometimes quite 
 noticeable. 
 
 The treatment from a medical standpoint is the giving of 
 iron in some form. Many claim it to be a specific, yet one writer 
 says that "THE BODY CAN GET MORE IRON OUT OF A CABBAGE LEAF 
 THAN FROM A SPOONFUL OF THE DRUG." The osteopath believes 
 in giving iron, but in the form of fruits, etc., the highly colored 
 fruits containing an abundance of iron in a form that can be 
 assimilated*. Good air, exercise and deep breathing are almost es- 
 sential in the treatment of chlorosis if good results are expected. 
 These coupled with the correction of the spinal lesions mentioned 
 above will cure in 95 per cent, of cases. On account of the weak- 
 ness of the abdominal wall and the frequency of enteroptosis, 
 lifting up treatments should be applied to the abdomen. This is 
 of assistance in relieving the constipation and promoting assimi- 
 lation. 
 
 LACK OF ORGASM. Orgasm is the "crisis of venereal 
 passion." The writer's apology for discussing this subject is 
 the fact that there are so many cases in which the SEXUAL PASSION 
 is DIMINISHED OR ENTIRELY lost, thus making the sexual act pos- 
 itively repugnant. Such conditions give rise to conjugal unhap- 
 piness and many a divorce proceeding has for its real cause some 
 disorder like the above. 
 
 Orgasm depends upon a healthy condition of the PUDIC 
 nerve. There must be erection of parts, that is of clitoris, va- 
 gina and lesser lips, and a sensory nerve connecting parts with the 
 center in the spinal cord and brain. The pudic nerve ends in 
 the clitoris and is the sensory nerve by which the impulses are 
 carried to the spinal cord. ANYTHING IMPAIRING THE FUNCTION
 
 510 DISEASES OF WOMEN. 
 
 OF THIS NERVE, that is peripherally or along its course, or a 
 diseased condition of the spinal cord, thus interfering with the 
 reception of the impulses will THUS INTERFERE with orgasm. 
 
 The MOST IMPORTANT of all causes is a DISEASED condition 
 of the CELLS in the SPINAL CORD. They are in such a condition 
 that they do not receive impulses carried to them over the pudic 
 nerve. This may be the result of an error in development. The 
 writer has one patient, one of twins, in which these cells were 
 never developed, at least the parts remain perfectly passive dur- 
 ing coitus, there being no indication of sexual passion. Most 
 cases come from lesions affecting the cells of origin of the pudic 
 nerve, ranging from the tenth dorsal to the fourth lumbar verte- 
 bra, or from sexual abuses such as excesses. The most common 
 lesion is found in the lower thoracic region. 
 
 The symptoms consist of a perversion of the sexual act in 
 which voluptuous sensation is lessened or entirely lost. Steril- 
 ity, atrophy of the ovaries and a lessening of the vaginal secre- 
 tions complicate. Menstrual disturbances are often found, such 
 as amenorrhea and delayed menstruation. The general effects 
 are often marked, the most important being despondency and 
 nervousness. The patient looks on the dark side of things, has 
 the "blues" and is in an unsatisfied, restless condition. Most 
 of the time the marital relations are unsatisfactory and often 
 separation follows. 
 
 In the acquired cases, cures have been performed by cor- 
 recting the spinal cord disturbance. This was accomplished 
 by securing good, normal circulation to and from the spinal cord 
 and relieving the pressure on the pudic nerve. These things 
 are accomplished by adjusting the spine, there being lesions 
 which are responsible. SEXUAL REST must be secured or at least 
 the function properly regulated.
 
 MISCELLANEOUS AFFECTIONS. 511 
 
 In the congenital form little or nothing can be done, at least 
 
 writer has failed in such cases. The subject is one of vital 
 importance since so much mental suffering is entailed by it. 
 
 SCIATICA complicating uterine disease, is very important 
 although not noted or treated in the vast majority of cases. 
 Sciatica is a painful condition of the great sciatic nerve due to 
 congestion or inflammation of the nerve. In the MILD types 
 ONLY CONGESTION exists, but in the more aggravated types a 
 true neuritis is present. 
 
 The causes of sciatica in the female can be included under 
 two heads; INFLAMMATION OF THE UTERUS OR ITS ADNEXA, or 
 PRESSURE on the roots of the nerve; and a LESION of one or more 
 of the BONES FORMING the PELVIS, most frequently a backward 
 twist of the innominate bone on the affected side. I BELIEVE 
 
 THAT A MILD TYPE OF SCIATICA COMPLICATES EVERY CASE OF ME- 
 
 TRITIS. There are several explanations for this; one is that the 
 VENOUS DRAINAGE of the nerve is affected by a stagnation of the 
 blood in the pelvis and this condition is always present in metritis. 
 The blood is forced back along the veins, the nerve congests, the 
 vascular pressure is thereby increased and pain follows; yet in 
 most cases this pain does not occur except on artificial pressure, 
 whereby the vascular pressure is increased. The NERVOUS CON- 
 NECTION furnishes another explanation. The SAME SEGMENT 
 of the cord which gives ORIGIN TO THE GREAT SCIATIC NERVK, CON- 
 TAINS the CENTER for the NERVES OF THE UTERUS. A stimulus 
 applied at the visceral end will cause an effect, motor or sensory 
 or both, in the posterior or in the other anterior branches. Possi- 
 bly Head's law will best explain the secondary disease. The 
 SAME LESION WILL PRODUCE BOTH DISEASES; that is, uterine dis- 
 turbances and sciatica. This to the osteopath is the most plausi- 
 . ble, since few vascular diseases, and I mean congestion and in-
 
 512 DISEASES OF WOMEN. 
 
 flammation of the female genitalia, are not caused or exaggerated 
 by some lesion of the bony pelvis. This, therefore, leads us to 
 the most important cause of sciatica in women, viz: a subluxa- 
 tion OF THE INNOMINATE. The particular type of lesion is a 
 BACKWARD ROTATION which is the most common of all innomi- 
 nate lesions, for reasons named later. This lesion affects the 
 sciatic nerve since it is in relation with its roots and course. This 
 lesion affects the vaso-motor nerves of the sciatic nerve and the 
 uterus, thereby causing vascular disturbances in both. Also as 
 stated above, the lesion is responsible for both the uterine dis- 
 ease and the sciatica, hence it is not a purely reflex disturbance 
 as it is supposed by many to be. 
 
 Some cases of sciatica are due to PRESSURE OF AN INFLAMED 
 UTERUS on the roots of the sciatic nerve. One of the worst cases 
 ever treated by the author was due to a retroflexed uterus which 
 had adhered to the nerve. The ordinary treatments had little 
 effect and an operation was advised. Abdominal fixation was 
 performed, which resulted in a cure. 
 
 The indications of sciatica are pain or ache along the course 
 of the nerve, being most intense at points at which the nerve is 
 most superficial, coldness of limb, cramping of hip or limb 
 and distinct tenderness on pressure at a POINT MIDWAY BETWEEN 
 the TUBEROSITY of the ISCHIUM and the GREAT TROCHANTER. 
 The author makes it a routine practice in the examination of all 
 cases of female disease to make this test; that is, PRESSURE OVER 
 
 THE NERVE AT THE ABOVE MENTIONED POINT. When Sciatica IS 
 
 thus diagnosed, a better explanation of limb disturbances is 
 furnished. 
 
 The treatment consists in correcting the bony and visceral 
 lesions, viz: the luxated innominate and the uterine displace- 
 ment, or if these do not exist, relieve the pelvic congestion or 
 inflammation.
 
 MISCELLANEOUS AFFECTIONS. 513 
 
 EYE STRAIN or severe aching of the eyes is often associated 
 with uterine disease. The pain is either in the ball of, or just 
 immediately above, the eye. There is usually an error in re- 
 fraction as the predisposing cause. The pain is a great deal 
 worse during the menstrual period. I recently had a case in 
 which the ache could not be relieved by the ordinary neck treat- 
 ment, but when the uterine displacement was corrected, the pain 
 instantly left. The seat of the pain is in the fifth cranial nerve, 
 the reason being that it has such a CLOSE CONNECTION WITH THE 
 SYMPATHETIC SYSTEM by the numerous sympathetic ganglia sit- 
 uated upon it. 
 
 PIGMENTATION of the skin is sometimes found as a result of 
 female disease. I treated a case of retroflexion of the uterus, 
 with irregular or delayed menses, in which PIGMENTED SPOTS 
 about an inch in diameter would appear in crops on the chest 
 and neck. These spots are usually called liver spots and are 
 attributed to some liver disturbance. The liver is usually to 
 blame, but not always, since I have cured many cases by relieving 
 the pelvic disturbances. In some cases of uterine disease a diffuse 
 pigmentation occurs, assuming the form of a pasty, dirty brown 
 color. The complexion is very sallow and cadaverous; the skin 
 appearing to be dead. THIS FORM OF PIGMENTATION OCCURS 
 
 ESPECIALLY IN DEGENERATIVE DISEASES OF THE OVARIES, Such 
 
 as CYSTIC DEGENERATION. It also occurs in renal and capsular 
 diseases. 
 
 LEUCODERMIA is in some cases due to pelvic disease. The 
 writer has treated and seen cases treated of this kind in which 
 there were irregular white patches covering the entire body. In 
 most of these cases uterine disease was present and when corrected 
 the white patches disappeared. The most common form of 
 uterine disease was metritis complicated by displacement and 
 
 33
 
 514 DISEASES OF WOMEN. 
 
 menstrual irregularities. Leucodermia occasionally appears in 
 the male. 
 
 During pregnancy yellowish brown spots appear on the face 
 and neck, sometimes on other parts of the body. Also they 
 accompany uterine polypi if symptoms of pregnancy are pres- 
 ent. The pigmentation will disappear and the skin regain its 
 natural color if uterine and liver troubles are corrected. 
 
 CHRONIC INGUINAL AND FEMORAL HERNIA are occas- 
 ionally met with in the female, though not so commonly, as in 
 the male. If the opening is small and the bowel stays up pretty 
 well, and the patient keeps off her feet and avoids straining her- 
 self, the outlook for a cure is fairly good if osteopathic treatment 
 is given. By lifting the bowel and developing the abdominal 
 muscles by certain well directed exercises coupled with some 
 manipulation applied to the affected part, at least relief if not a 
 cure can be effected. If the bowel comes down often, a properly 
 fitted truss should be worn. 
 
 Hernia of the partial variety may come on suddenly and pro- 
 duce symptoms of appendicitis and various other acute intes- 
 tinal diseases. It consists of the bowel being forced PARTLY 
 THROUGH the internal abdominal ring or THROUGH THE OMENTUM. 
 It follows strains or vigorous muscular actions and its onset is 
 very sudden. The pain is very acute and cramp-like. If on the 
 right side it may be mistaken for acute appendicitis or ovarian 
 disease, since the pain radiates upward and is localized in many 
 cases at or near McBurney's point. On palpation the tumor 
 can be felt at the abdominal ring and is very sensitive on pressure. 
 The ovary may be implicated and the pain reflected to the back 
 by way of the ovarian plexus. In either case the patient should 
 be placed in the Trendelenburg position and the intestines lifted 
 out of the pelvis. By a deep gentle manipulation of the abdomen
 
 MISCELLANEOUS AFFECTIONS. 515 
 
 with an upward motion this can be accomplished and the patient 
 instantly relieved. 
 
 PHLEGMASIA ALBA DOLENS, or what is commonly called 
 "milk leg," is a disease which follows parturition. The acute 
 form is supposed to be the result of septic infection. The in- 
 fection takes place primarily in the uterus and extends to the 
 femoral vein, resulting in an inflammation or phlebitis. This 
 results in venous obstruction and enormous swelling of the affected 
 leg. The disease was formerly supposed to be due to metastasis 
 of milk. 
 
 The acute form starts with a chill followed by fever and 
 painful swelling of the leg. This swelling takes place in most 
 cases from below up and is characterized by a RED LINE along the 
 course of the femoral vein and by such a TENSENESS that the 
 skin does not pit on pressure. 
 
 In cases that do not terminate fatally, the disease runs a 
 chronic course and it is this form that comes within the scope of 
 this work. The chronic form is characterized by atrophy, weak- 
 ening and loss of sensibility in the affected limb ; the limb seems 
 to be dead and is cold a great deal of the time. In some the 
 limb is strong enough to permit standing and walking, in others 
 the paralysis is complete. The chalky, atrophied appearance 
 plus the history of an attack in the limb as a sequel to labor 
 make the diagnosis unquestioned. 
 
 As stated above, the supposed cause of "milk leg" is septic 
 infection. The writer believes this to be a mistake and would 
 beg leave to substitute TRAUMA as a cause of the disease. The 
 form of trauma is an injury of the LUMBAR VERTEBRAE, or of the 
 INNOMINATE BONE. During pregnancy all these joints become 
 more movable, this acting as a predisposition to a luxation of 
 either a vertebra or the innominate. During labor the EXTREME
 
 516 DISEASES OF WOMEN. 
 
 AMOUNT OF FORCE brought to bear on these parts sometimes re- 
 sults in a luxation. The most common lesion is a strain or slip 
 of one of the innominate bones. This is true in cases in which 
 the limbs are extremely flexed on the abdomen. In the few 
 cases of milk leg the writer has seen (the careful osteopathic 
 obstetrician prevents the disease) the above mentioned lesion 
 was found and when corrected the patient recovered. In all 
 chronic cases, and we see many, an INNOMINATE OR HIP LESION 
 WAS FOUND IN EVERY ONE. If the case is not too chronic the 
 prognosis is favorable, but if very chronic it, like all chronic 
 cases of long standing, is hard to cure. Also the degree of atrophy 
 and weakness must be considered when making up the prognosis. 
 
 The treatment is the osteopathic one directed to the correc- 
 tion of the above mentioned lesions. The prophylactic treatment 
 consists of a THOROUGH EXAMINATION OF THE HIPS AND INNOM- 
 i NATES at the conclusion of labor, AND ADJUSTING ANY DISPLACE- 
 MENT FOUND. The author usually rotates the hips immediately 
 after labor if patient complains of any pain or cramping in the 
 limbs. 
 
 In chronic cases a SUBINVOLUTED uterus may be present 
 which aggravates the condition and must be corrected before a 
 complete cure is effected. 
 
 DISEASES OF THE KNEE AND FOOT often complicate 
 pelvic disturbances. Synovitis of the knee joint is the most com- 
 mon. There is at first a slight swelling around the joint, usually 
 described as a "puffy" condition, coupled with some tenderness 
 and stiffness. The swelling increases until the knee is very much 
 enlarged, which is attended by the usual symptoms of inflamma- 
 tion. 
 
 On local vaginal examination, in many of these cases, an 
 inflamed or prolapsed ovary was found on the same side. These con-
 
 MISCELLANEOUS AFFECTIONS. 517 
 
 ditions were accompanied by a uterine displacement, it being 
 back and down. The correction of the pelvic disturbances cured 
 all these cases in which the synovitis was secondary. Usually 
 a twisted condition of the innominate is responsible for both the 
 pelvic disease and synovitis of the the knee and deserves first at- 
 tention. After the correction of the bony lesions, replacement 
 of the prolapsed viscera will result in a complete cure. 
 
 THE ERUPTIONS OF THE SKIN in female diseases occur 
 most frequently as a complication of menstrual disorders. The 
 most common, as well as harmless, is, in many women, the HER- 
 PETIC ERUPTION on the lip at each menstrual period. In others 
 acne, in a chronic form furnishes a very undesirable eruption and 
 one for which all kinds of cosmetics are used. It is worse at each 
 menstrual period; and at puberty is often very bad on account 
 of the increase in amount of inflammation, giving the face a 
 mottled appearance. The sebaceous glands fail to perform their 
 function and there is a retention of the secretions, giving rise to 
 irritation and inflammation. In such cases perspiration in the 
 affected region is stopped, the part appearing oily, or as the pa- 
 tient often expresses it "greasy." 
 
 An IMPERFECT EMPTYING of the uterus at the menstrual 
 period is given as a CAUSE. The general change in the blood at 
 the menstrual period, it becoming impoverished, is a better cause. 
 The patient is anemic and mal-nourished, which condition is 
 perhaps a cause rather than an effect. MASTURBATION and EX- 
 CESSIVE VENERY are also mentioned as causes, or rather such 
 conditions are associated. In some cases this is true, that is mas- 
 turbation is the underlying cause, but eruptions on the face are 
 not necessarily diagnostic of masturbation. There is some re- 
 lation between the genitalia and skin of the face and back, and 
 in a vast majority of cases a diseased or perverted condition of
 
 518 DISEASES OF WOMEN. 
 
 the genitalia exists if there are eruptions on face and back. 
 
 The treatment consists primarily in correcting the PELVIC 
 DISTURBANCES, if any exist, and some local treatment to face 
 and neck. The pelvic trouble is usually a menstrual one such as 
 retention of or scanty menses ; in others, pathological congestions 
 with hypersecretions, which weaken the body by impairing the 
 blood. The correction of CERVICAL LESIONS is important since 
 the vaso-motor supply to the face is affected by such. Pimples 
 follow localized stagnation and putrefaction of blood. A toxic 
 condition from other causes produces inflammation and pus forma- 
 tion, therefore to cure facial eruptions improve the quality of 
 the blood and secure good circulation through the face. 
 
 A MOLE OF THE UTERUS is denned as a TUMOR resulting 
 from death of the embryo with proliferation of the cells of the 
 deciduae. In missed abortion the placenta or chorion may con- 
 tinue to develop, or at least not loosen and become expelled. The 
 embryo is absorbed and soon a fleshy mass is formed IN UTERO. 
 The cause possibly lies in a diseased endometrium. 
 
 The most important symptom is HEMORRHAGE AND PAIN. 
 The flooding occurs at irregular intervals and is often marked, 
 leaving the patient weak, anemic and very much exhausted. 
 On local examination the uterus is found to be symmetrically 
 enlarged; that is, the patient appears to be pregnant, judging 
 from the shape, tone and position of the uterus. During the at- 
 tack a part of* the mass, which resembles placental tissue, is ex- 
 pelled. At this time the patient appears to be in hard labor and 
 in the cases seen by the author, the pains were a great deal worse 
 than in an ordinary labor case. These uterine contractions keep 
 up until the mole is expelled, this taking quite a while and usually 
 requires assistance in the form of the application of abortion for- 
 ceps or curettement. If all the growth is not removed it will
 
 MISCELLANEOUS AFFECTIONS. 519 
 
 continue to enlarge and the patient has another "spell." If the 
 uterus is ENTIRELY EMPTIED of this flesh-like growth it seldom 
 returns. 
 
 The TREATMENT, therefore, consists of emptying the uterus 
 of this mass which can best be accomplished by the use of the 
 dull curette. 
 
 In DIAGNOSING this condition remember that most of the 
 
 EARLY INDICATIONS OF PREGNANCY ARE PRESENT, which things 
 
 are of assistance in differentiating it from subinvolution and 
 fibroid tumors of the uterus. 
 
 There is a rare form called false mole, which is not depend- 
 ent on pregnancy. This form is derived from fibroid tumor, 
 endometritis, in which there is a desquamated cast of the mucous 
 membrane, or retained coagula of menstrual blood. The treat- 
 ment is about the same in all forms, viz: securing expulsion. In 
 the false form, resort is seldom made to the use of instruments, 
 the tumor being expelled by securing contraction of the uterus. 
 
 LEUCORRHEA IX CHILDREN occasionally occurs. It, 
 like the adult form, is caused by congestion of the vagina or 
 uterus, usually the former, There are two causes responsible 
 for the cases treated by the writer, viz: lesions along the lower 
 thoracic and upper lumbar spine, and specific infection setting 
 up a catarrhal condition of the vaginal mucous membrane. 
 
 The diagnosis is based on the lesions found and the micro- 
 scopical examination. A cure can be effected in nearly every 
 case produced by the first named cause. This is accomplished 
 by correcting the spinal lesion. The cases belonging to the sec- 
 ond named cause are DIAGNOSED by finding the gonococci in the 
 discharge; and TREATED by applying antiseptic solutions to the 
 diseased area. (See specific vaginitis.)
 
 520 DISEASES OF WOMEN. 
 
 DISEASES OF THE RECTUM AND ANUS. A great many 
 diseases of the rectum and anus in the female are secondary to 
 pelvic disorders. This is explained by the PROXIMITY OF THE 
 BOWEL with its nerves and blood vessels, to the uterus and its 
 adnexa. 
 
 The rectum commences at the sacro-iliac synchondrosis 
 with which it is in close relation, crosses to the middle of the sac- 
 rum, sometimes past the median line, and then passes down be- 
 tween the sacro-uterine ligaments to the uterus. The upper part 
 is invested with peritoneum while the lower part is not, it being 
 in direct relation with the vagina anteriorly, and the coccyx and 
 levator ani posteriorly. The upper part of the rectum is in rela- 
 tion with the cervix uteri and with the body and fundus when the 
 uterus is retro-deviated, hence the importance of examining for 
 uterine trouble in cases of disturbance of this part of the bowel. 
 The rectu m is drained by the hemorrhoidal plexus of veins. This 
 plexus anastomoses with the other plexuses in the pelvis. The 
 blood vessels that drain the rectum drain the uterus; and the 
 nerve plexus that supplies the one, sends filaments to the other. 
 This furnishes another explanation for diseases of the rectum com- 
 plicating uterine disease. 
 
 The anus is the external aperture of the intestine. The 
 orifice is surrounded by integment puckered into folds, which is 
 the result of contraction of the sphincter muscles. The lining 
 of this portion of the intestinal tract is smooth and is subject to 
 relaxation and prolapsus. The principal thing to remember re- 
 garding the anus is that the ANAL BRANCH OF THE PUDIC NERVE 
 SUPPLIES THE LOWES. PART, hence the sexual derangements fol-. 
 lowing diseases of the anus. 
 
 The injuries of the rectum, except those from direct trauma 
 as in falling on a sharp object, come almost entirely from parturi-
 
 MISCELLANEOUS AFFECTIONS. 521 
 
 tion. Laceration of the perineum, pressure on the bowel by the 
 descending head of the fetus resulting in eversion of the anus, 
 and over stretching of the posterior vaginal wall which results in 
 rectocele are the common injuries from childbirth. Complete 
 laceration of the perineal body is the worst form of injury and 
 results in marked disturbance of function of the rectum, vagina, 
 uterus and pelvic floor. Infection is likely to occur unless the 
 parts are kept very clean, there being an unprotected point at 
 which the germs make their attack. 
 
 Fissure of the anus sometimes complicates retro-displace- 
 ment of the uterus. The pressure of the uterus on the bowel 
 affects the circulation of blood through it. This also causes 
 chronic constipation which is the important cause of fissure. The 
 hard fecal matter passing over the delicate mucous membrane 
 of the bowel results in injury to it, such as erosion or tears of the 
 mucous tissue. 
 
 PAIN is the most constant symptom of anal fissure and varies 
 with the severity of the case. In some the pain is constant, the 
 patient with difficulty finding a position of ease. It is not con- 
 fined to the anus but radiates to the lower limbs and lumbar re- 
 gion. In all cases the pain is necessarily worst during defeca- 
 tion. 
 
 The diagnosis is based on inspection, the fissure usually being 
 low enough to be readily seen. In straining at stool blood is 
 often discharged and the anal mucous membrane everted. On 
 local vaginal examination, the body of the uterus is found to be 
 in many cases, low down and back against the bowel. 
 
 The treatment consists of correction of the uterine displace- 
 ment, ADJUSTING THE COCCYX and sacrum and relieving the con- 
 stipation. 
 
 Proctitis and rectal abscesses often, like fissure, come from 
 pressure of a retro-displaced uterus.
 
 522 
 
 DISEASES OF WOMEN. 
 
 STRICTURE also comes from a similar cause. At first it is 
 temporary, that is the uterus obstructs the bowel ; later an irrita- 
 tion is set up, perhaps abscesses form, and the scar tissue result- 
 ing, produces a permanent stricture. The writer has seen 
 temporary stricture complicate anteversion with a backward 
 slipping of the uterus, thus forcing the cervix into the bowel, 
 obliterating its lumen. Chronic constipation results in such cases. 
 
 Fistulae in ano complicate pelvic diseases in many instances. 
 A fistula, meaning a pipe, is defined as "an abnormal, tube-like 
 passage in the body" and when applied to the anus is an abnormal 
 channel of communication between the bowel and the surface in 
 the neighborhood of the anus. This channel is formed by the 
 
 Fig. 109 Showing different forms of rectal fistulae, (diagrammatic). 
 
 efforts of pus to escape from a pus cavity. The PUS CAVITY is 
 the result of decomposed blood; that is, the blood dies from lack 
 of movement and pus formation begins. This stagnation of the 
 blood comes oftenest from pressure and in the female, from a retro-
 
 MISCELLANEOUS AFFECTIONS. 523 
 
 displaced uterus pressing on the blood vessels of the tissues in 
 and around the bowel. 
 
 There are THREE FORMS OF FISTULAE; the COMPLETE, in 
 which there is a continuous sinus with an opening upon the mu- 
 cous membrane and another externally; the BLIND INTERNAL, 
 in which there is no external opening; and the BLIND EXTERNAL, 
 in which there is no connection with the bowel. The form is 
 determined by the amount and location of pus and the direction 
 in which it burrows. 
 
 In some patients the symptoms are marked; in others, un- 
 important. PRURITUS with some inflammation at the orifice are 
 common. The diagnosis is based on locating the opening from 
 which pus is discharged. The extent can only be determined by 
 the use of a probe. In blind internal fistulae, the pus is expelled 
 per rectum and the opening located w r ith difficulty. 
 
 The TREATMENT consists in restoring normal drainage of the 
 diseased area, wilich is accomplished by replacing the uterus, 
 thus removing the pressure on the blood vessels. This coupled 
 with adjustment of the sacro-coccygeal and sacro-iliac articula- 
 tions will cure without an operation. In rare cases an operation 
 is advisable. 
 
 HEMORRHOIDS. On account of the frequency of hemor- 
 rhoids in the female and their association with female diseases, 
 a short description will not be amiss at this place. 
 
 A HEMORRHOID is a vascular tumor produced by a chronic 
 distention of the hemorrhoidal plexus of veins. This distention 
 is due to vaso-motor paralysis or a mechanical obstruction of 
 the vein. The latter is more common. This obstruction is 
 usually a retro-displaced uterus, and in EVERY CASE of hemor- 
 rhoids in the female, I would EXAMINE THE UTERUS for a displace- 
 ment or enlargement. A slipped innominate or chronic consti-
 
 524 
 
 DISEASES OF WOMEN. 
 
 pation in which there is impaction of the bowel, frequently im- 
 pedes the return flow and causes distention of these veins. Dur- 
 ing pregnancy they are increased in size. If enemata are used 
 
 Fig. 110. Showing veins in hemorrhoids, (diagrammatic). 
 
 very often while the bowel is impacted, as is the case in chronic 
 constipation, the engorged blood vessels will be forced down 
 and become enlarged, causing exquisite pain and agony until 
 replaced and the blood pressure in these veins lowered. 
 
 Chronic liver troubles also tend to produce hemorrhoids. 
 
 In TREATING hemorrhoids, look for the obstruction, whether 
 in the bowels, liver, uterus or whether it is due to muscular con- 
 tractions, and remove it. A local rectal treatment is occasionally 
 given whereby the mucous membrane of the bowel can be par- 
 tially relieved of its stagnated blood. If the hemorrhoid is a VAS-
 
 MISCELLANEOUS AFFECTIONS. 525 
 
 CULAR ONE and is external it SHOULD BE REPLACED AT ONCE. This 
 can be accomplished by anointing the tumor then using gentle, 
 but firm pressure against it until the sphincter relaxes. If re- 
 placement is impossible, hot applications or the use of a bread 
 and milk poultice applied in the evening and remaining over 
 night, make replacement possible on the following day, as well 
 as partly relieving the pain. In replacing use plenty of lubri- 
 cant, butter being one of the best. Keep the bowels free and 
 prevent the patient from straining at stool or standing on her 
 feet too long at a time. If pregnancy is the cause SHIFT THE 
 POSITION of the gravid uterus and keep the patient quiet. 
 
 If the hemorrhoid remains external very long, ITS WALLS 
 THICKEN and there is formed the chronic pile, which is fibrous in 
 character, irreplaceable and produces little trouble. 
 
 CONSTIPATION is also a common complication of diseases 
 of the female genitalia. There are several anatomical explana- 
 tions for this. The nerve supply of the levator ani muscle, the 
 rectum, vagina and uterus is very closely connected. On this 
 account, a diseased condition of one is likely to affect the other. 
 A general relaxation is the common condition. The mucous 
 membrane and sphincters prolapse, the lumen of the bowel thus 
 being partly closed and the mucous membrane loses its irrita- 
 bility, that is it is partly paralyzed. This may come from the 
 pressure of a retro-displaced uterus. PRESSURE AT FIRST NUMBS. 
 AFTERWARDS THE BOWEL PROLAPSES. This form of displacement 
 may mechanically obstruct the canal, or, as mentioned before, 
 an ante verted uterus with retro-position, thus forcing the cervix 
 into the bowel, will produce a similar effect. 
 
 Diarrhea sometimes occurs at the menstrual period, it being 
 the result of the increased congestion occurring at that time. 
 The pressure of a displaced uterus on the bowel may at first cause 
 diarrhea; later on, constipation.
 
 526 DISEASES OF WOMEN. 
 
 THE MICROBIC ORIGIN of disease is a subject much dis- 
 cussed of late. It is quite a fad to attribute every disease to 
 some micro-organism. In fact, it has become such a common 
 thing that a great many people suffer from microphobia, being 
 in constant fear of some dread microbe attacking them. THE 
 BODY is PROTECTED AGAINST all microbic invasion, if the skin and 
 mucous membrane are in perfect working order. If the blood is 
 circulating properly and the skin and mucous membranes are 
 intact, no microbe can enter the system. Gonorrhea will not 
 attack a healthy person, but let an alcoholic subject be exposed, 
 or one that is weakened by excesses and it readily infects the sub- 
 ject. Microbes, then, are the exciting causes in the diseases in 
 which they are found, while the predisposing cause is a weakness 
 due to excesses or lesions which interfere with the proper circu- 
 lation of the blood. Vaginal secretions are acid and effectually 
 bar the entrance of bacteria. Mucous membranes unless they are 
 broken are self cleansing and need no artificial antiseptics. 
 However, if they are abraded an artificial antiseptic is required. 
 On this account and also from the fact that the amniotic fluid and 
 local discharges are antiseptic, injections are not advocated after 
 delivery. A strong antiseptic injures the delicate mucous mem- 
 brane and cells are destroyed by it, and this predisposes to the 
 entrance of bacteria, since dead tissue is the best, in fact the only 
 kind of nidus suitable for their propagation. I do not deny the 
 fact that microbes are found in a great many diseases, but I do 
 deny the theory that they are the cause of disease. They are the 
 result of disease. Dr. Still once said to me that the "BUZZARD WAS 
 THE BIGGEST MICROBE THAT HE KNEW". It feeds on dead flesh 
 or tissues; so do the microbes, and so long as the tissues are alive 
 the bacteria cannot affect them, but so soon as there is cell deca--' 
 they, being ever present, pounce upon that part and there read-
 
 MISCELLANEOUS AFFECTIONS. 527 
 
 ily propagate. The OSTEOPATHIC IDEA is TO KEEP THE TISSUES 
 HEALTHY, thus preventing cell decay. This is accomplished by 
 keeping the blood moving, and if any one can control circula- 
 tion it is the proficient osteopath. 
 
 CARE OF THE HANDS. Since the osteopath comes in close 
 contact with the patient, the hands should at all times be kept 
 scrupulously clean. In making a local examination see that 
 the nails are pared and clean. If there is an abrasion on the ex- 
 amining finger use some other finger or defer the examination, 
 if it is a doubtful case. The finger, if venereal disease or cancer 
 is present, should be protected by glycerine or a heavy coat of 
 vaseline. 
 
 Always thoroughly cleanse the hands before treating the 
 next patient or infection may be transmitted. I have seen cases 
 in which infection was carried by the physician on account of a 
 lack of cleanliness. Again, it is a good plan to wash the hands 
 in the presence of the patient since it leaves the impression that 
 you are cleanly. After treating a case of venereal disease be 
 careful not to carelessly introduce the finger into the eye, or the 
 poison may become transmitted to the mucous membrane and 
 produce ophthalmia. 
 
 RHEUMATISM. I have collected quite a number of cases 
 of rheumatism which were traced to menstrual disorders as the 
 cause. If the menses are retained it produces rheumatic symp- 
 toms, such as soreness in the muscles, swelling of the joints with 
 the characteristic shifting of the pain from one joint to another. 
 
 In some there were sweats, this being due to retention of the sub- 
 stances which were not thrown off at the menstrual period, and 
 the skin taking on the function of additional excretion. In others, 
 the symptoms of rheumatoid arthritis are most pronounced, in 
 fact, I regard this disease as due in most cases to retention of the 
 menses.
 
 528 DISEASES OF WOMEN. 
 
 It is rare to get this disease in the male and when it is found, 
 the kidneys are usually diseased. I have cured quite a number 
 of cases of initiatory rheumatoid arthritis by regulating the men- 
 strual flow. If the case is treated before the structural changes 
 take place in the joint, a cure is almost certain, but after the joint 
 changes have occurred, a cure is improbable, even if the men- 
 strual flow be regulated. 
 
 The treatment should be confined to the lumbar and sacral 
 regions, while the joints should not be manipulated at all, since 
 they are not at fault and should be left alone, or else they may 
 be bruised by manipulation. Strong stimulation over the lum- 
 bar region increases the arterial circulation to the uterus and is 
 very beneficial in menstrual disturbances. Bony lesions are 
 also found as the fundamental cause of these rheumatoid affec- 
 tions. 
 
 LESIONS OF THE BONY PELVIS. The pelvic bones are sub- 
 ject to a variety of twists or partial displacements on account of 
 the position of the pelvis, its function, and since it bears the brunt 
 of jars and falls, especially if the patient suddenly steps into a de- 
 pression. Some say that it is impossible for the innominate bones 
 to be displaced. If so, why is there an increase in the length of 
 one limb when the hip is not dislocated? Why is one innominate 
 higher than the other? Why is one spine more prominent than 
 the corresponding one? That they do take place is apparant 
 to one who has studied the subject or to one that has cured dis- 
 orders by correcting the displacement. 
 
 If a lesion does exist, then there will be, in most cases, an 
 irregularity in the bony prominences, tenderness at the articu- 
 lations or the length of the limbs will be affected. TENDERNESS 
 AT THE SYNCHONDROSES is the BEST INDICATION in recent cases of 
 a slight displacement of the innominates. Irregularity at the
 
 MISCELLANEOUS AFFECTIONS. 
 
 529 
 
 symphysis is a good indication of a rotated ilium. SHORTENING 
 
 OF THE LIMB INDICATES AN UPWARD slip OF BACKWARD rotation of 
 
 the ilium. The SACRUM is ALWAYS AFFECTED by slips of the in- 
 nominate bones. A prominent sacrum, indicates a backward 
 displacement of the lower part. A posterior lumbar region in- 
 dicates that the upper part of the sacrum is posterior and the 
 lower part is anterior. 
 
 FIG. Ill Showing how the weight of the body is supported by the pelvis. 
 
 The MOST COMMON displacement of the innominate, bones is 
 UPWARD and BACKWARD. That of the sacrum, a forward rotation 
 of the upper part and a backward rotation of the lower part. 
 This can be more plainly seen by reference to Fig. Ill, x, repre- 
 
 34
 
 530 DISEASES OF WOMEN. 
 
 sents the fifth lumbar vertebra; s, the sacro-iliac synchondrosis ; 
 h, the acetabulum; the three points are not in a straight line, but 
 form an angle, xsh. The force from below exerted at h, tends to 
 force the pelvis directly upward, but the ilium is hinged at s, 
 therefore, that part is moved with more difficulty than the sym- 
 physis pubis, and the force, instead of being directed upward, is 
 partly directed backward. If the force acts on both hips at the 
 same time, the pelvis is rotated upward and backward around the 
 pivots. On this account, a person who is on the feet a great deal, 
 or has had a hard fall directly on the feet, usually suffers from 
 this kind of displacement. The points x, and h, are approxi- 
 mated, and the angle xsh, is lessened. The force from above, 
 or the weight of the body, is supported at x, or the fifth lumbar. 
 It, like the force from below, is transmitted through an angle, 
 xsh and s, is a pivotal or fixed point around which the sacrum ro- 
 tates. Therefore, a force acting from above tends to force x 
 lower and by so doing the lower part of the sacrum is thrown 
 upward and backward, since s, is the FULCRUM and xs, the LEVER. 
 Each step or jar TENDS TO DRIVE THE SPINAL COLUMN lower, and 
 if the muscular and ligamentous supports are weakened so as 
 not to firmly fix the joints, a slipped sacrum follows. 
 
 The COCCYX is A MOVABLE BONE. Since the lower part of 
 the sacrum is thrown backward, the tip of the coccyx will be 
 drawn forward by the muscles and ligaments attached to it, and 
 form a sharp angle at the sacro-coccygeal articulation. This ex- 
 plains why a sharp angle is so frequently found at this joint, and 
 why the coccyx so often appears to be anterior. A posterior 
 curvature of the lumbar region may draw x backward, thus in- 
 creasing the angle xsh. In this case the upper part ef the sacrum 
 will be drawn backward and the lower part forward. Yet the 
 fifth lumbar may become posterior without drawing the sacrum
 
 MISCELLANEOUS AFFECTIONS. 531 
 
 with it, but it could not be thrown anterior without carrying the 
 top part of the sacrum forward, on account of the arrangement of 
 the articular processes. These lesions derange the pelvic circu- 
 lation, change the position and shape of the buttocks, and alter 
 the length of the limbs. The most important effect is the direct 
 interference with the pelvic circulation, producing menstrual 
 disorders, tumors and leucorrhea.
 
 532 
 
 DISEASES OF WOMEN. 
 
 INDEX. 
 
 ABDOMEN, examination of, 108. 
 
 Percussion of, 112. 
 
 temperature of, 112. 
 
 tenderness of, 109. 
 Abdominal wall ,subin volution of, 367. 
 
 tone of, 367. 
 Abdominal fixation, 216. 
 Abdominal pregnancy, 502. 
 Abortion, 498. 
 
 as cause of disease, 86. 
 
 causes of, 499. 
 
 in endometritis, 352. 
 
 inevitable, 501. 
 
 sequellae, 500. 
 
 symptoms of, 500. 
 
 threatened, 501. 
 
 treatment, 501. 
 
 Abscess of vulvo-vaginal gland, 146. 
 Acquired anteflexion, 232. 
 Adhesions, peritoneal, 257, 377. 
 
 breaking up of, 258. 
 
 vaginal, 377. 
 
 Alexander's operation, 217. 
 Amenorrhea, 397. 
 
 causes of, 398. 
 
 classification of, 398. 
 
 drugs in, 407. 
 
 pathologic .il, 404. 
 
 physiological, 404. 
 
 treatment of, 408. 
 Amputation of cervix, 332. 
 Anal fissurj, 523. 
 Anus, diseases of in female, 522. 
 Angina pectori^. 475. 
 
 Anteflexion, 225. 
 
 causes, 232. 
 
 classification, 230. 
 
 congenital, 232. 
 
 diagnosis, 239. 
 
 irreducible, 231. 
 
 lesions in, 234. 
 
 replacement, 242. 
 
 obstacles to, 243. 
 
 sterility in, 238. 
 
 unequal involution in, 235. 
 
 symptoms, 236. 
 
 varieties, 230. 
 Ante version, 217. 
 
 chronic metritis as cause, 219. 
 
 diagnosis, 221. 
 
 replacement, 223. 
 
 symptoms, 221. 
 
 use of uterine repositor in, 223. 
 Aphonia in hysteria, 483. 
 Arbor vitae, 38. 
 Arrest of development, 80. 
 Ascites, 
 
 differentiated from ovarian cyst. 
 
 461. 
 
 Astringents in hemorrhage, 310 
 Atrophy of uterus, 383. 
 
 BACKACHE in retroflexion 251 
 Bartholins glands, 26. 
 
 abscess of, 146. 
 
 cyst of, 145. 
 
 diseases of, 145. 
 
 inhibition of, 27.
 
 INDEX. 
 
 5*3 
 
 relation to pelvic floor, 27. 
 
 swelling of, 146. 
 Belt in fibroid tumor, 309. 
 Bimanual examination, 123. 
 
 object, 125. 
 
 Binder, objection to, 250. 
 Bivalve speculum, 128. 
 Bladder, 59. 
 
 examination of, 134. 
 
 nerves, 61. 
 
 trigone, 60. 
 
 vessels, 61. 
 Bony pelvis, 71. 
 
 lesions of, 528. 
 Breasts, 503. 
 
 cancer of, 506. 
 Broad ligaments, 46. 
 
 contents of, 46. 
 
 shape, 46. 
 
 tenderness in, 48. 
 
 twisting of, 48. 
 
 varicosity in, 48. 
 Bulbs of the vagina, 25. 
 Bush women, 21. 
 
 CACHEXIA of cancer, 320. 
 Canal of Xuck, 19. 
 Carcinoma of uterus, 314. 
 
 causes, 315. 
 
 discharge in, 318. 
 
 differential diagnosis, 321 . 
 
 hemorrhage in, 317. 
 
 pain in, 139. 
 
 signs of, 320. 
 
 straw color, 320. 
 
 symptoms of, general, 319. 
 
 treatment of, 323. 
 
 varieties, 315. 
 Cardiac reflexes, 474. 
 Carunculae myrtiformes, 29. 
 Caruncle of urethra, 59. 
 Catalepsy, 486. 
 Causes of disease, general, 76. 
 
 Cerebral reflexes, 472. 
 Cervix uteri, 
 
 anatomy, 35. 
 
 different forms, 121. 
 
 erosion, 335. 
 
 laceration of, 336. 
 Chlorosis, 508. 
 Civilization, 79. 
 Clavus hystericus, 483. 
 Clitoris, 21. 
 
 amputation of, 24. 
 
 blood supply, 23. 
 
 hooded, 21. 
 
 inhibition of, 23. 
 
 nerve supply, 24. 
 
 stimulation, 22. 
 Clitoridectomy, 24. 
 3occyx displacement of, 162. 
 Cold feet, 480. 
 Colpitis, 154. 
 Coccydynia, 172. 
 
 Complications of uterine displace- 
 ment, 284. 
 Constipation, 81. 
 
 resulting from pelvic disease,525. 
 Congenital anteflexion, 231. 
 Corporeal anteflexion, 230. 
 Corporeo-cervical anteflexion, 230. 
 Corset, 83. 
 
 Criminal abortion, 87. 
 Curettage of uterus in fibroids, 311. 
 
 in membraneous dysmenorrhea, 
 
 433. 
 Cysts of vagina, 171. 
 
 of ovary, 460. 
 Cystic degeneration, 464. 
 
 indications of, 465. 
 Cystitis, 221, 236. 
 Cystocele, 164. 
 
 DELAYED menstruation, 436. 
 Dermoid cyst of ovary, 459.
 
 534 
 
 DISEASES OF WOMEN. 
 
 Development of female genital or- 
 gans, 12. 
 
 date, 12. 
 
 differentiation of sex, 12. 
 
 Fallopian tubes, 14. 
 
 ovaries, 13. 
 
 Mullerian ducts, 14. 
 
 uterus, 14. 
 
 uterus bicornis, 15. 
 
 Wolffian ducts, 12. 
 Diameters of pelvis, 73. 
 Digital examination, 115. 
 Disease, general causes, 76. 
 
 exciting, 98. 
 
 parturition as cause, 99. 
 Displacements of uterus, 187. 
 
 general symptoms of, 188. 
 Douches vaginal, 174. 
 
 effects of, 175. 
 
 when indicated, 176. 
 Dress, 83. 
 Dysmenorrhea, 418. 
 
 from anteflexion, 237, 422. 
 
 from endometritis, 426. 
 
 from erosion of cervix, 423. 
 
 from faulty development, 424. 
 
 from infantile uterus, 424. 
 
 from lesions, 421, 423. 
 
 from obstruction, 422. 
 
 from polypi, 313. 
 
 from prolapsus, 197. 
 
 from retroflexion, 253. 
 
 pain in, 419. 
 
 varieties, 420. 
 
 membraneous, 414. 
 
 ECTOPIC gestation, 502. 
 Education as cause of disease, 76. 
 Emansio mensium, 397. 
 Endometritis, 345. 
 
 abdominal indications, 352. 
 
 abortion in, 352. 
 
 causes, 345. 
 
 curettement in, 354. 
 
 gonorrheal type, 356. 
 
 lesions in, 347. 
 
 lymphatic glands in, 350. 
 
 membraneous dysmenorrhea in, 
 
 350. 
 
 menstruation in, 349, 416. 
 
 pathology of, 345. 
 
 prophylaxis, 355. 
 
 reflexes in, 351. 
 
 secretions in, 350. 
 
 sterility in, 351. 
 
 uterine displacement in, 347. 
 Epithelioma of uterus, 315. 
 Erosion of cervix, 335. 
 Eruption on face, 517. 
 Examination, 
 
 abdominal, 108. 
 
 bimanual, 123. 
 
 of bladder and urethra, 134. 
 
 of pelvis, 136. 
 
 of rectum, 132. 
 Examination of vagina, 114. 
 
 of vulva, 113. 
 
 of young girls, 114. 
 
 positions, 115. 
 
 subjective, 105. 
 
 with speculum, 127. 
 Exercises in prolapsus, 213. 
 Exposure during menses, 103. 
 Extra-uterine pregnancy, 502. 
 
 symptoms of, 502. 
 Eye strain, 513. 
 
 FALLOPIAN tubes, 
 
 anatomy of, 51. 
 
 diseases of, 439. 
 
 Faulty development of uterus, 424. 
 Fibroid tumors, 292. 
 
 causes, 298. 
 
 differential diagnosis, 304. 
 
 lesions in, 299. 
 
 pain in, 302.
 
 INDEX. 
 
 535 
 
 physical signs, 303. 
 
 structure of, 294. 
 
 symptoms, 301. 
 
 varieties of, 294. 
 Fibromata, 293. 
 Fibro-myomata, 292. 
 Fimbia ovariana, 52. 
 Fissure of anus, 523. 
 Fistula in ano, 524. 
 Flatus vaginalis, 171. 
 Foot, diseases of in female, 518. 
 Fossa navicularis, 24. 
 Fourchet, 29. 
 Frenulum, 20. 
 
 GARRULITY of vagina, 171. 
 Gastralgia, 470. 
 Genital corpuscles, 22. 
 Genu-pectoral position, 118. 
 Globus hystericus, 483. 
 Glans clitoridis, 22. 
 Glandular reflexes, 476. 
 Glands, mammary, 503. 
 Gonorrhea, 101. 
 
 in female, 158. 
 
 Goitre from pelvic irritation, 477. 
 Gonococci of Xeiser, 159. 
 Graafian follicles, 55. 
 Green sickness, 508. 
 Gynecological treatment as cause of 
 
 disease, 100. 
 Gynecology. 
 
 basic principle, 7. 
 
 definition, 6. 
 
 history, 7. 
 
 HANDS, care of, 527. 
 Headache, 467. 
 Hemicrania, 468. 
 Hemidrosis, 478. 
 Hemometra, 403. 
 Hemorrhoids, 525. 
 Hemorrhage in polypi, 313. 
 
 Hernia in female, 514. 
 Heredity, 78. 
 Hiccough, 473. 
 Hot flashes, 386. 
 Hymen, 27. 
 
 types, 27. 
 
 remains, 29. 
 Hysteria, 481. 
 
 aphonia in, 483. 
 
 contractures in, 483. 
 
 eyeballs in, .483. 
 
 lesions in, 484. 
 
 sensory- disturbances, 482. 
 Hysterical temperature, 483. 
 Hysperesthesia, 479. 
 Hystero-epilepsy, 448, 485. 
 Hysterorraphy, 216. 
 
 IMPACTED bowel, 305. 
 
 Infancy, 379. 
 
 Infantile uterus, in menstrual dis- 
 orders, 425. 
 
 Inflammation of uterus, 340. 
 
 Insanity, 472. 
 
 Insomnia, 473. 
 
 Inspection, 113. 
 
 Intestinal reflexes, 475. 
 
 Interstitial fibroid, 296. 
 
 Intramural fibroid, 296. 
 
 Irregular menses, 437. 
 
 Irreducible flexion, 231. 
 
 Inversion of uterus, 286. 
 causes, 287. 
 diagnosis, 290. 
 partial 305. 
 symptoms, 289. 
 treatment, 291. 
 
 KNEE, diseases of in female, 518. 
 Kraurosis vulvae, 151. 
 
 LABIA majora, 18. 
 Labia minora. 20.
 
 536 
 
 DISEASES OF WOMEN. 
 
 in new born, 21, 
 Laceration of cervix, 326, 334. 
 
 causes, 326. 
 
 signs, 329. 
 
 symptoms, 328. 
 
 treatment, 331. 
 
 varieties, 327. 
 Laryngeal reflexes, 471. 
 Latero-flexion, 283. 
 Latero- version, 283. 
 Lesions in female diseases, 87. 
 
 coccyx, 96. 
 
 rib, 90. 
 
 sacrum, 94. 
 Leucodermia,513. 
 Leucorrhea, 490. 
 
 symptoms, 492. 
 
 in children, 519. 
 
 in retroflexion, 252. 
 Levator ani muscle, 68. 
 
 MAMMARY glands, 503. 
 
 cancer of, 506. 
 
 diseases of, 505. 
 
 size, indication of, 504. 
 Mastitis, 476. 
 Masturbation, 495. 
 
 effect on nervous system, 497. 
 
 effect on bowels, 497. 
 
 symptoms, 496. 
 Maturity, 381. 
 Meatus urinarius, 59. 
 Membraneous dysmenorrhea, 414,427 
 Menstruation, 393. 
 
 causes, 393. 
 
 delayed, 436. 
 
 disorders of, 397. 
 
 flow in, 395. 
 
 molimina in, 394. 
 
 sudden cessation of, 428. 
 Menopause, 382. 
 
 changes at, 383. 
 
 dangers, 387. 
 
 menstruation in, 385. 
 
 premature, 384. 
 
 reflexes, 386. 
 Menorrhagia, 409. 
 
 abortion, 417. 
 
 bony lesions in, 410. 
 
 displacement in, 412. 
 
 diagnosis of, 415. 
 
 effects, 415. 
 
 enteroptosis, 413. 
 
 in fibroids, 309. 
 
 spinal treatment in, 413. 
 Metritis, 357. 
 
 acute, 364. 
 
 abdomen in, 361. 
 
 bony lesions, 357. 
 
 in retroflexion, 251. 
 
 secretions, 366. 
 
 sudden prolapsus as cause, 359. 
 
 tone in, 359. 
 
 uterine displacement in, 362. 
 
 with endometritis, 357. 
 Metrorrhagia, 397. 
 
 in cancer, 317. 
 Micturition, center, 60. 
 
 frequent, 236. 
 Migraine, 468. 
 Milk leg, 517. 
 Mole, uterine. 520. 
 Mons Veneris, 18. 
 Mucous polypus, 312. 
 Myoma, 292. 
 
 NABOTHIAN cysts, 329, 36. 
 Nausea from displaced ovary, 470, 
 
 446. 
 
 Neiser gonococcus of, 159. 
 Nipple, inverted, 455. 
 Nuck, canal of, 19. 
 Nymphae, 20.
 
 INDEX. 
 
 537 
 
 OBESITY in amenorrhea, 401. 
 Occupation, 81. 
 Orgasm in female, 22. 
 
 seat of, 493. 
 
 lack of, 509. 
 Os uteri, 36. 
 
 Ovariotomy effects of, 465. 
 Ovaries, 53. 
 
 blood supply, 56. 
 
 congestion of, 449. 
 
 development of 444. 
 
 displacement of, 444. 
 
 function of, 56. 
 
 Graafian follicles in, 53. 
 
 ligaments of, 54. 
 
 nerve supply, 57. 
 
 rib lesions affecting, 449. 
 Ovarian pain, 447. 
 Ovarian abscess, 458. 
 
 colic, 430. 
 
 cysts, 460. 
 
 reflexes, 446. 
 Ovaritis chronic, 453. 
 
 reflexes in, 455. 
 
 symptoms of, 454. 
 Ovulation, 391. 
 
 PAIN, 419. 
 Parovarium, 58. 
 
 Palpitation from uterine displace- 
 ment, 474. 
 Pelvis. 
 
 connective tissue of, 70. 
 
 examination of, 136. 
 
 floor of, 67. 
 
 peritoneum, 65. 
 
 planes of, 73. 
 Pelvic cavity, false, 72. 
 
 true 72. 
 Perimetritis, 372. 
 
 causes, 373. 
 
 effects, 377. 
 
 specific infection in, 373. 
 
 symptoms, 374. 
 
 treatment, 375. 
 Perineum, 69. 
 
 descent, 69. 
 
 nerve supply, 69. 
 Perineal body, 68. 
 Pessaries, 43. 
 Pharyngeal reflexes, 471. 
 Phlegmasia alba dolens, 517. 
 Physometra, 403. 
 Physiological periods, 379. 
 Physical signs of prolapsus, 197. 
 Pigmentation, 513. 
 Polypus of uterus, 311. 
 
 diagosis 313. 
 
 treatment, 314. 
 Polarity, 425. 
 Positions, 115. 
 Pouch of Douglas, 65. 
 Precocious menstruation, 436. 
 Prepuce, 20. 
 Procidentia, 187. 
 Prolapsus uteri, 
 
 causes, 190. 
 
 diagnosis, 195. 
 
 effect on adnexa, 199. 
 Prolapsus uteri. 
 
 prognosis, 201. 
 
 replacement, 202. 
 
 treatment, 201. 
 Protracted menstruation, 438. 
 Pruritus vulvae, 147. 
 Puberty, 379. 
 
 changes at, 380. 
 Pyosalpinx, 440. 
 
 RECTOCELE, 168. 
 Recto-uterine ligament, 46. 
 Rectum, 61. 
 
 diseases of, 520. 
 
 examination of, 132. 
 
 function, 64. 
 
 nerves, 64.
 
 538 
 
 DISEASES OF WOMEN. 
 
 relations of, 62. 
 
 structure of, 524. 
 
 vessels of, 64. 
 Reflex disorders, 466. 
 Retroflexion, 245. 
 
 causes, 246. 
 
 degrees, 246. 
 
 lesions in, 246. 
 
 replacement of, 258. 
 Retro version, 269. 
 
 causes, 270. 
 
 degrees, 269. 
 
 diagnosis, 275. 
 
 symptoms, 274. 
 
 treatment, 276. 
 
 replacement, 277. 
 Rheumatism, 529, 478. 
 Rheumatoid arthritis, 530, 478. 
 Rima pudendil 19. 
 Round ligament, 49. 
 
 SACRO-ILIAC articulation, 74. 
 Sacro-coccygea articulation, 74. 
 Sacro-uterine ligament, 44. 
 Salpingitis, 440. 
 
 acute, 440. 
 
 chronic, 442. 
 
 gonorrhea!, 441. 
 Sarcoma of uterus, 324. 
 Scanty menstruation, 408. 
 Sciatica, 511. 
 
 in retroflexion, 251. 
 Senility, 390. 
 Sim's position, 117. 
 Sound, 209. 
 
 Speculum, examination with, 127. 
 Spinal irritation, 479. 
 Spinal column in tumors, 299. 
 Stenosis of os, 434. 
 Stem pessary, 214. 
 Sterility, 86, 488. 
 
 in retroflexion, 253, 489. 
 
 lesions in, 489. 
 
 Stomach disorders, 469. 
 Subin volution, 
 
 laceration in, 367. 
 
 lesions, 366. 
 
 nursing in, 367. 
 
 symptoms, 368. 
 Submucous fibroid, 295. 
 Subperitoneal fibroid, 297. 
 Subjective examination, 105. 
 Supports of uterus, 211. 
 Suppressio mensium, 397. 
 Superin volution, 371. 
 Sweat glands, 478. 
 
 TAMPONS, 215. 
 
 Torsion of uterus, 284. 
 
 Tonsils, 471. 
 
 Trachelorraphy, 331. 
 
 Traumatism as cause of disease, 103. 
 
 Trendelenburg position, 119. 
 
 Tumors of uterus, 292. 
 
 classification, 292. 
 
 definition, 292. 
 
 fibroid, 292. 
 
 curettage in, 311. 
 
 diagnosis of, 305. 
 
 operations in, 310. 
 
 prognosis, 306. 
 
 rest treatment in, 308. 
 
 treatment of, 306, 311. 
 
 ULCERATION of cervix, 339. 
 Unequal development of uterus, 235. 
 Urethra, 58. 
 
 examination of, 134. 
 Uterus bicornis, 15. 
 Uterine mole, 518. 
 Uterine repositor, 206. 
 Uterus, 34. 
 
 arbor vitae, 38. 
 
 blood supply, 40, 341. 
 
 body, 37. 
 
 cavity, 37.
 
 INDEX. 
 
 539 
 
 cervix, 35. 
 endometrium, 39. 
 glands in, 39. 
 ligaments, 42. 
 lymphatics of, 41. 
 mobility, 34. 
 nerves, 41. 
 
 normal position, 179. 
 os externum, 36 
 parts, 34. 
 relations, 178. 
 size, 34. 
 supports, 183. 
 walls, 39. 
 
 VAGINA, 29. 
 
 blood supply, 33. 
 examination of, 114. 
 fornices, 39. 
 function, 32. 
 lymphatics, 33. 
 nerves, 33. 
 
 rugae, 31. 
 Vaginal examination, 
 
 things to be noted in, 120. 
 Vaginal secretions, 155. 
 Vaginismus, 161. 
 Vaginitis, 154. 
 
 symptoms, 159. 
 Varicose veins of vulva, 151. 
 Vesico-uterine ligament, 43. 
 Vestibule, 24. 
 Vicarious menstruation, 434. 
 
 forms, 435. 
 
 treatment of, 435. 
 Vulva, examination of, 113. 
 
 injuries of, 153. 
 Vulvitis, 140. 
 
 causes, 140. 
 
 symptoms, 142 
 
 treatment, 144. 
 
 WOLFFIAN bodies, 12. 
 Wire uterine repositor, 263.
 
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